American Society of Regional Anesthesia and Pain Medicine August 2017 - 31

Neuraxial Anesthesia Versus General Anesthesia in Spine Surgery
Patients: Benefits, Risks, and Why It Should Be Considered
Lumbar disc disease encompasses several pathological processes
including disc space collapse, annular tearing, desiccation of
the nucleus pulposus, and disc bulging, causing symptoms of
neurologic compromise, radiculopathy, and back pain. While the
first laminectomy and discectomy was described in the literature
almost 100 years ago, the advent of the surgical microscope in
the 1970s brought about the modern microdiscectomy, making the
wide exposure required with laminectomy unnecessary.1,2
Most disc disease may be treated by nonsurgical means, but when
pain is unremitting or a neurologic deficit exists, surgery may be
necessary. Commonly accepted indications for surgery include
a six-week failure of conservative management, new neurologic
deficits during conservative treatment, and patients who know
that surgery is likely and do not wish to invest time in conservative
treatment. Emergent indications include the acute development of a
motor deficit and cauda equina syndrome.3
Lumbar spine surgery can be performed under general anesthesia,
neuraxial anesthesia, or local anesthetic infiltration with monitored
anesthesia care. General anesthesia is the most common technique
for lumbar spine surgery, reasons for which are multifactorial.
Anesthesiologists may be more comfortable with general
anesthesia as the airway is secured in the prone position, surgeries
of greater duration can be performed, and there is the perception
of greater patient acceptance.4 Despite its greater use, there
are disadvantages to general anesthesia, including less stable
hemodynamics, more nausea and vomiting, greater intraoperative
blood loss, and more need for rescue analgesics postoperatively.5
In addition to general and spinal anesthesia, discectomy procedures
can be performed safely and effectively under local anesthesia if
done endoscopically. This technique offers several advantages over
microdiscectomy including shorter post anesthesia care unit (PACU)
stays and decreased postoperative pain, bleeding, length of stay,
and overall recovery time.6
NEURAXIAL ANESTHESIA CAUTIONS
Patient, procedure, and surgeon selection are extremely important
when performing spine surgery under spinal anesthesia. Like
all regional anesthetics, the patient must be consentable and
cooperative. The patient should not be hypovolemic or have a fixed
cardiac outflow obstruction. The patient cannot be coagulopathic
nor be allergic to local anesthetics. There cannot be infection at
the spinal injection site. Finally, this technique should be avoided
in patients with intracranial hypertension.7 Due to the duration of
spinal anesthesia, this technique should probably be avoided in
procedures lasting more than 3 hours and therefore may preclude
its use in complex surgery, in teaching environments, or with less
experienced surgeons. Anesthesiologists should take the same
precautions as for any patient in the prone position, with special
consideration for the unsecured airway. Special care should be

Shelly B. Borden, MD
Assistant Professor
Regional Anesthesia and Acute Pain
Management
University of Wisconsin
Madison, WI

Roland Flores, MD
Assistant Professor
Regional Anesthesia and Acute Pain
Management
University of Colorado
Denver, CO

Section Editor: Kristopher Schroeder, MD

taken in patients with obstructive sleep apnea, issues with neck
mobility, obesity, or a known difficult airway. The possibility of
losing the airway in the prone position with limited choices in
useful airway devices and an inability to perform normal airway
rescue maneuvers must be taken into account when considering
this technique.8 One must also consider the profound decrease in
preload that can occur with neuraxial anesthesia and the use of the
kneeling position that is oftentimes utilized for minimally invasive
spine surgery.
NEURAXIAL ANESTHESIA BENEFITS AND TECHNIQUE
Studies support the use of neuraxial anesthesia over general
anesthesia in certain lumbar spine surgery patients. The potential
advantages of regional anesthesia include the lack of airway
instrumentation, stable hemodynamics, a shorter hospital stay, and
reduced health care costs. According to a meta-analysis published
this year, the use of spinal anesthesia for lumbar spine surgery is
associated with a lower incidence of intra-operative hypertension
and tachycardia, reduced opioid and other analgesic requirements
in the PACU, less postoperative nausea and vomiting (PONV) at
24 hours, and a shorter hospital length of stay compared with
general anesthesia.9 This study also suggests that there are no
differences between the anesthetic techniques in terms of intraoperative hypotension, blood loss, surgical time, and PONV in the
PACU.9 Notably, no studies to date report any increased neurologic
complications with spinal anesthesia versus general anesthesia
administration for spine surgery.
Decreased blood loss with the use of neuraxial anesthesia is a
hypothetical advantage due to reduced episodes of intraoperative
hypertension, reduced venous congestion, and lower intrathoracic
pressure in a spontaneously ventilating patient. However, the

American Society of Regional Anesthesia and Pain Medicine
2017

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