Anesthesiology is a field with a number of subspecialties, including cardiac, obstetric, pediatric, geriatric, neurologic, regional, critical care and pain medicine.1 Neuroanesthesia in particular can allow for even further specialization, such as a focus on spinal surgery.2 With the combination of innovative, minimally invasive techniques in spine surgery and an aging population, anesthesia for spine surgery is becoming increasingly important and unique.2 Anesthesiology professionals who specialize in spine surgery must have knowledge of the procedure itself, perioperative patient care and current research in anesthetic drugs for spine surgery.
An anesthesia provider may take part in various types of spine surgery. These include vertebroplasty and kyphoplasty to fix compression fractures in the vertebrae caused by osteoporosis; spinal laminectomy to decompress the spinal column; discectomy, which is the removal of a herniated disk that presses on a nerve root or the spinal cord; foraminotomy to enlarge the bony hole where a nerve root exits the spinal canal; nucleoplasty, which is laser surgery for people with low back pain; spinal fusion, which is fusion of vertebrae with bone grafts or screws; and artificial disk replacement to treat severely damaged disks.3 The anesthesia provider should have in-depth knowledge of the procedure and associated anesthetic techniques before surgery.2 Anesthesia professionals are also responsible for preoperative preparation of the patient, intraoperative vital signs monitoring and proper anesthetic technique and postoperative complication prevention.4 This includes preoperative patient education about expectations for the procedure and postoperative recovery from anesthesia.5 Armaghani et al. emphasize preoperative counseling that encourages minimal opioid use.6 Additionally, the neuroanesthesia professional will need to work closely with the surgical and nursing teams to optimize patient care during and after surgery.5 According to Smith et al.’s study an enhanced program for lumbar spine fusion, collaboration between the neuroanesthesia and neurosurgery departments and specialized use of anti-nausea and anti-pain medications in high-risk patients led to decreased postoperative nausea, a shorter duration of opioid use and a decrease in long-acting opioid use.5 The neuroanesthesiology professional’s role is to prepare thoroughly for surgery, educate the patient and collaborate with other teams throughout the perioperative period.
Recent research and advancements in anesthesia have led practitioners to conduct spine surgery without general anesthesia.7 Awake spine surgery has several advantages over conventional spine surgery, including the possibility of patient participation, rapid postoperative recovery and reduced risk of complications from general anesthesia.7 A local anesthetic technique that is widely used for awake spine surgery is spinal anesthesia.8 Spinal anesthesia is a type of neuraxial anesthesia in which a local anesthetic is injected into fluid in the lumbar spine to anesthetize nerves exiting the spinal cord.8 According to a study on lumbar laminectomy by McLain et al., spinal anesthesia was as safe and effective as general anesthesia, with advantages such as reduced anesthesia duration, nausea, antiemetic and analgesic requirements and complications.9 Patil et al. found that these advantages extended to high-risk lumbar spine surgery patients by reducing morbidity and mortality and providing hemodynamic stability.10 Deng et al. also found an advantage in hemodynamic stability, leading to decreased intraoperative use of vasoactive agents and drugs in general.11 While Baenziger et al. did not find a difference between regional and general anesthesia for morphine consumption after lumbar spine surgery, regional anesthesia was associated with shorter anesthesia and transition times, lower pain and higher patient satisfaction.12 Additionally, Attari et al. found that spinal anesthesia was superior to general anesthesia for lumbar disk surgery due to reduced blood loss, increased hemodynamic stability and better postoperative analgesia.13 Lessing et al.’s study also showed that spinal anesthesia was a viable method of anesthesia for patients 70 years of age or older undergoing lumbar spine surgery.14 Evidently, spinal anesthesia is a safe alternative to general anesthesia and may decrease pain, medication use and risk of complications while increasing hemodynamic stability and patient satisfaction.
Neuroanesthesiologists who specialize in spine surgery have a unique role in patient care. New innovations in health care require spine surgery anesthesia professionals to thoroughly study surgical procedures and anesthetic techniques. Preoperative patient education and perioperative collaboration with other medical teams is crucial to a spine surgery’s success. Additionally, anesthesia providers are responsible for choosing between general anesthesia and spinal anesthesia, which may prove to be a better option. In the future, researchers should evaluate the efficacy of different anesthetic drugs and dosages in anesthesia for spine surgery, as well as optimal positioning of the patient.15
1. American Society of Anesthesiologists. Guide to a Career in Anesthesiology. ASA Medical Student Component 2020; https://www.asahq.org/education-and-career/asa-medical-student-component/guide-to-a-career-in-anesthesiology.
2. Gould RW. Anesthesia for Spine Surgery. Anesthesiology: The Journal of the American Society of Anesthesiologists. 2013;119(1):240–241.
3. American Society of Anesthesiologists. Back Surgery. When Seconds Count… Physician Anesthesiologists Save Lives 2020; https://www.asahq.org/whensecondscount/preparing-for-surgery/procedures/back-surgery/.
4. Brown MD, Seltzer DG. Perioperative care in lumbar spine surgery. The Orthopedic Clinics of North America. 1991;22(2):353–358.
5. Smith J, Probst S, Calandra C, et al. Enhanced recovery after surgery (ERAS) program for lumbar spine fusion. Perioperative Medicine. 2019;8(1):4.
6. Armaghani SJ, Lee DS, Bible JE, et al. Preoperative Opioid Use and Its Association With Perioperative Opioid Demand and Postoperative Opioid Independence in Patients Undergoing Spine Surgery. Spine. 2014;39(25):E1524–E1530.
7. Gary MF, Wang MY. Spinal Surgery Without General Anesthesia. Contemporary Spine Surgery. 2016;17(5):1–5.
8. DeLeon AM, Wong CA. Spinal anesthesia: Technique. In: Crowley M, ed. UpToDate. Web: Wolters Kluwer; December 18, 2019.
9. McLain RF, Kalfas I, Bell GR, Tetzlaff JE, Yoon HJ, Rana M. Comparison of spinal and general anesthesia in lumbar laminectomy surgery: A case-controlled analysis of 400 patients. Journal of Neurosurgery: Spine. 2005;2(1):17–22.
10. Patil H, Garg N, Navakar D, Banabokade L. Lumbar Spine Surgeries Under Spinal Anesthesia in High-Risk Patients: A Retrospective Analysis. World Neurosurgery. April 2019;124:e779–e782.
11. Deng H, Coumans J-V, Anderson R, Houle TT, Peterfreund RA. Spinal anesthesia for lumbar spine surgery correlates with fewer total medications and less frequent use of vasoactive agents: A single center experience. PLoS One. 2019;14(6):e0217939.
12. Baenziger B, Nadi N, Doerig R, et al. Regional Versus General Anesthesia: Effect of Anesthetic Techniques on Clinical Outcome in Lumbar Spine Surgery: A Prospective Randomized Controlled Trial. Journal of Neurosurgical Anesthesiology. 2020;32(1):29–35.
13. Attari MA, Mirhosseini SA, Honarmand A, Safavi MR. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: A randomized clinical trial. Journal of Research in Medical Sciences. 2011;16(4):524–529.
14. Lessing NL, Edwards CC, Brown CH, et al. Spinal Anesthesia in Elderly Patients Undergoing Lumbar Spine Surgery. Orthopedics. 2017;40(2):e317–e322.
15. Lyzogub M. Spinal anesthesia for lumbar spine surgery in prone position: Plain vs heavy bupivacaine 8AP3-6. European Journal of Anaesthesiology. 2014;31:133.