Regional_Anesthesia_for_Spine_Surgery.1.pdf

Review Article
Regional Anesthesia for Spine Surgery
ABSTRACT
Current advancements in spine surgery have led to a recent interest in
regional anesthesia for spine surgery. Spinal anesthesia, epidural
anesthesia, and their combination are commonly used modalities for
regional anesthesia in spine surgeries. The successful use of regional
anesthesia has led to the emergence of several new concepts such as
awake spinal fusion and outpatient spinal surgery. Regarding analgesic
techniques, several new modalities have been described recently such
as erector spinae and thoracolumbar interfascial plane blocks. These
regional analgesic modalities are aimed at decreasing perioperative
pain and enhancing early recovery in patients undergoing spine
surgery. This narrative review focuses on the techniques, indications
and contraindications, benefits, and complications of regional
anesthesia in the context of spine surgery.
R
egional anesthetic techniques such as spinal, epidural, or their com-
bination constitute an alternative approach to general anesthesia for
lower thoracic and less extensive lumbar procedures such as
laminectomy and diskectomy. Regional anesthesia offers several advantages
such as no airway instrumentation, sound analgesia, stable hemodynamic
profile, lower blood loss, andless postoperative nausea and vomiting (PONV),
whereas intraoperative anxiety, cough, hiccups, and minor movements con-
stitute the potential drawbacks for this modality.1-3 Regional modalities of
anesthesia integrated with the minimally invasive and endoscopic techniques
of spinal surgery also form the basis of newer concepts such as “awake spinal
fusion,” “outpatient spine surgery,” and “enhanced recovery after spine
surgery.”4-8 This narrative review focuses on the techniques, indications and
contraindications, benefits and complications, and recent application of
intraspinal and paraspinal modalities of regional anesthesia and analgesia.
Intraspinal Modalities
Spinal Anesthesia
Ditzler et al initially described the use of spinal anesthesia for lumbar disk
herniation surgery in 1959. Since then, several researchers have evaluated
the risks and benefits of spinal anesthesia for selected spinal procedures1,9,10
(Table 1). Spinal anesthesia has been demonstrated to have better safety,
efficacy, and cost-effectiveness profiles when compared with general
Bhavuk Garg, MS
Kaustubh Ahuja, MS
Alok D. Sharan, MD, MHCDS
From the Department of Orthopaedics, All India
Institute of Medical Sciences, New Delhi, India
(Garg), the Department of Spine Surgery,
Indraprastha Apollo Hospital, New Delhi, India
(Ahuja), and WESTMED Spine Center, Yonkers,
NY (Sharan).
Sharan or an immediate family member serves
as a consultant for Paradigm Spine, GLOBUS,
MCRA, and Simplify. Neither of the following
authors nor any immediate family member has
received anything of value from or has stock or
stock options held in a commercial company or
institution related directly or indirectly to the
subject of this article: Garg and Ahuja.
J Am Acad Orthop Surg 2022;30:809-819
DOI: 10.5435/JAAOS-D-22-00101
Copyright 2022 by the American Academy of
Orthopaedic Surgeons.
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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

anesthesia for spinal procedures. Recent interest in
regional anesthetic techniques for spinal surgery has led
to several researchers conducting meta-analyses and
systematic reviews to investigate the safety and efficacy
of spinal anesthesia over general anesthesia. Meng et al
in a recent meta-analysis demonstrated a lower inci-
dence of intraoperative hypertension and tachycardia
with reduced need of postoperative analgesia and
PONV with spinal anesthesia as compared with general
anesthesia. The investigators found no difference in the
incidence of intraoperative hypotension, bradycardia,
blood loss, and OR duration between the two modali-
ties.3 Zorrilla-Vaca et al11 in another meta-analysis
demonstrated several advantages of regional anesthesia
such as lower PONV, blood loss, and length of stay.
Both meta-analyses demonstrated clinical superiority of
regional anesthesia over general anesthesia in hemody-
namic profile, PONV, and length of hospital stay. In
addition, higher patient and doctor satisfaction rates
have been reported in patients undergoing lumbar mi-
crodiskectomies with spinal anesthesia over general
anesthesia.12
Spinal anesthesia is commonly administered in the
sitting or lateral decubitus position at an appropriate
spinal level, followed by turning the patient supine for a
few minutes to allow the block to settle. The patient can
be repositioned to a sitting, knee-chest, lateral, or prone
position according to the familiarity and preference of the
surgeon once an adequate level of anesthesia (typically
T6-T8) is achieved. A recent study analyzed the effect of
positioning on the hemodynamic profile in patients
administered with spinal anesthesia. The authors
demonstrated a higher fall in blood pressure with a
higher need for pressors, atropine, and glycopyrrolate in
patients pre-positioned in a knee-chest position as com-
pared with patients positioned supine after spinal anes-
thesia for 20 minutes, followed by repositioning in the
knee-chest position.13 A possible explanation is the
longer time available in supine patients for accommo-
dation for vasodilation in lower limbs.
Commonly used anesthetic agents for spinal anes-
thesia consist of a long-acting local anesthetic such as
bupivacaine with fentanyl. Before spinal administration,
an infusion of 400 to 600 mL of crystalloid is preferable
to expand the intravascular volume. For intraoperative
sedation, propofol infusion, midazolam, or fentanyl may
be administered as per the anesthetist’s discretion. Lev-
obupivacaine has been shown to have a shorter block
recovery time as compared with bupivacaine and,
therefore, may help in early postoperative neurological
examination.14
Epidural Anesthesia
A major drawback of spinal anesthesia is the limited time
available for the surgery. Epidural anesthesia is an
effective alternative because it can be used to top up the
anesthetic medication in prolonged surgery allowing a
longer surgical time. Nevertheless, epidural anesthesia is
not commonly used as a primary anesthetic modality for
lumbar spine surgery for several reasons. Epidural
anesthesia, in contrast to other modalities, takes a longer
time to administer, has an inconsistent distribution of
anesthetic solution, and thus, has an unpredictable depth
of anesthesia.15 In addition, several surgeons find the
epidural catheter as an obstruction in the operating
field. These factors have restricted the use of epidural
anesthesia as an adjunct with spinal or general anes-
thesia for lumbar and lower dorsal surgeries. There are
only a limited number of articles in the literature
describing the role of epidural anesthesia for lumbar
surgery (Table 2). When compared with general anes-
thesia, epidural anesthesia has been reported to have a
lower incidence of PONV and lesser blood loss.16 The
biggest advantage of epidural anesthesia is postopera-
tive analgesia and reduced requirement of opioids in
patients undergoing laminectomies or diskectomies.
Epidurally injected local anesthetics with or without
opioid form an important component of the multimodal
pain control strategy for spinal surgery. Epidural anes-
thesia has been found to markedly reduce the postoper-
ative opioid requirement and opioid-related
complications.17 The local anesthetics and opioids in-
jected in the epidural space act by desensitization of
local nociceptors resulting in the blockage of neural
transmission of pain signals. This blockage of pain at the
spinal level is an important component of preemptive
analgesia and is known to markedly reduce the post-
operative pain scores and improve patient outcomes.17
Ropivacaine is better suited than lidocaine or bupiv-
acaine because it preserves the motor function and has
the least cardiovascular or central nervous
system–related adverse effects.18
Several studies have assessed the efficacy of epidural
infusion as a part of the analgesic regimen. Two ran-
domized controlled trials (RCTs) by Park et al19 and
Gessler et al20 have reported markedly less pain scores
and postoperative opioid consumption in patients
receiving 0.2% epidural ropivacaine when compared
with intravenous (IV) patient-controlled analgesia
morphine. Joshi et al21 reported better outcomes for
pain control in patients undergoing lumbar laminec-
tomy with epidural fentanyl infusion as compared with
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Table 1. Studies Comparing the Effect of Spinal Anesthesia Versus General Anesthesia
References Design Surgery RA Technique GA Technique Outcome
Jellish 1996 RCT (122) Laminectomy or disk
surgery (L1-2)
Bupivacaine 0.75%
(11 mg) intrathecally
Induction (thiopental
1 fentanyl),
vecuronium (for
intubation only), and
maintenance
(isoflurane 1 N2O
70%)
Shorter total
anesthesia time
More
hemodynamically
stable
Less postoperative
pain and nausea
Tetzlaff 1998 Retrospective
(803)
More
hemodynamically
stable
Less DVT; less
nausea
Dagher et al
2002
RCT (69) Microdiskectomy (L1) Bupivacaine 0.5%
(3-3.5 mL) intrathecally
Induction (propofol 1
fentanyl), vecuronium
(for intubation only),
and maintenance
(isoflurane 1 N2O
70%)
Higher satisfaction
scores
Early ambulation
Less nausea and
vomiting
McLain et al
2004
Case-control
(200)
Laminectomy or
laminotomy for spinal
stenosis or herniated
disk
0.75% bupivacaine in
8.5% dextrose
solution
Induction: sodium
thiopental and
fentanyl (1-5 mg/g);
maintenance: fentanyl
1 isoflurane 1
vecuronium nitrous
oxide/oxygen (70%/
30%)
Shorter total
anesthesia time
Lower intraoperative
MAP and HR
Lesser nausea and
urinary retention
McLain et al
2005
Case-control
(400)
Laminectomy or
laminotomy for spinal
stenosis or herniated
disk
15 mg of 0.5% plain
bupivacaine, 2 mg of
fentanyl, and 0.2 mg of
epinephrine
Induction: sodium
thiopental (3-5 mg/kg)
or propofol (2 mg/kg)
and fentanyl (1-5 mg/
g); maintenance:
fentanyl 1 isoflurane
(0.5-1.5%) in nitrous
oxide/oxygen (70%/
30%)
Shorter anesthesia
and surgery duration
Lesser
postoperative
analgesia, nausea,
and vomiting
Sadrolsadat
et al 2009
RCT (100) Laminectomy for
lumbar disk herniation
(L1-2)
Bupivacaine 0.5%
(4 mL) intrathecally,
sedation (propofol
low-rate infusion)
fentanyl), atracurium
(for intubation and
maintenance), and
maintenance
(propofol and
alfentanil infusion)
Less surgeon
satisfaction
Less hypotension
More postoperative
nausea and
vomiting
Attari et al
2011
RCT (72) Diskectomy and
laminectomy (level
unspecified)
Bupivacaine 0.5%
(3.0-3.2 mL) and
fentanyl 25 mg
intrathecally and
sedation (propofol
low-rate infusion)
lidocaine 1 fentanyl),
atracurium (for
maintenance
(isoflurane 1 N2O
50%)
Lesser blood loss,
more stable, higher
surgeon satisfaction
scores, and lesser
pain
Kahveci 2014 RCT (80) Lumbar spinal surgery
(L1)
Bupivacaine 0.5%
(3 mL) intrathecally
fentanyl), atracurium
(for intubation and
Hemodynamically
stable
(continued)
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Bhavuk Garg, MS, et al

IV morphine administered through patient-controlled
analgesia for pain control. Not all studies had results in
favor of postoperative epidural analgesia. Choi et al22
reported comparable opioid consumption in a treatment
group receiving 0.1% bupivacaine and hydromorphone
when compared with a placebo group which received
0.9% saline infusion.
Apart from local anesthetics, the use of corticosteroids
alone or in combination with opioids through the epi-
dural route has also been studied.23 Local administration
Table 1. (continued)
References Design Surgery RA Technique GA Technique Outcome
and sedation (propofol
low-rate infusion)
maintenance), and
maintenance
(sevoflurane)
Less surgeon
satisfaction, lower
cost
Kara 2012 RCT (60) Diskectomy Levobupivacaine
0.5% (10 mg)
intrathecally
fentanyl), rocuronium
(for intubation only),
and maintenance
(desflurane 1 N2O
60%)
Lesser tachycardia
and hypertension,
shorter anesthetic
and surgical times,
lesser pain and
analgesia, PONV
lesser surgeon
satisfaction,
comparable
ambulation, LOS,
urinary retention, and
headache
Vural 2014 RCT (66) Lumbar disk herniation
(L1)
Bupivacaine 0.5%
(15 mg) intrathecally
Induction (thiopental
1 fentanyl),
rocuronium (for
maintenance
(desflurane 1 N2O
50%)
EBL, patient
satisfaction, pain
and analgesia,
PONV, urinary
retention, headache,
and costs
DVT = deep vein thrombosis, EBL = estimated blood loss, HR = heart rate, LOS = length of stay, MAP = mean arterial pressure, PONV =
postoperative nausea and vomiting, RCT = randomized controlled trial
Table 2. Articles Comparing Epidural Versus General Anesthesia for Spine Surgery
Reference Design Surgery Outcome
Demirel et al 2003 RCT Lumbar partial hemilaminectomy and
diskectomy
Longer time to incision and equal total
anesthesia time, less blood loss, and
less postoperative nausea and
vomiting
Yoshimoto 2005 Prospective Posterior lumbar spinal fusion Lower MAP, less blood loss, and less
need for postoperative analgesics
Papadopoulos et al 2006 Cohort Lumbar microdiskectomy Equal surgery time, less nausea
vomiting, and equal hospital stay
Yoshikawa 2011 Retrospective Percutaneous endoscopic lumbar
diskectomy
Longer OR room time and equal length
of stay
Ezhevskaya et al 2013 RCT Reconstructive spine surgery More hemodynamically stable and less
pain and postoperative nausea and
vomiting
Khajavi et al 2013 RCT Lumbar spine disk surgery Lesser blood loss and lesser
hemodynamic disturbance
MAP = mean arterial pressure, OR = operating room, RCT = randomized controlled trial
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of corticosteroids around the decompressed nerve root
after removing the disk is a routine practice at our
institution. Corticosteroids inactivate the enzyme
phospholipase A2 and counter the inflammatory aspect
of pain in a prolapsed disk. Intraoperative epidural
bupivacaine and corticosteroids also ensure complete
pain relief on the first postoperative day in patients
undergoing diskectomy, thus allowing early mobiliza-
tion and a better patient satisfaction rate as opposed to
saline.23
Paraspinal Modalities
Erector Spinae Block
The erector spinae plane block is a novel technique for
trunk fascia block that was first described in 2016. Apart
from spine surgery, its role has also been described for
abdominal analgesia in weight loss surgery and breast
procedures. Only a few studies have been published to
date to evaluate its role in pain management in patients
undergoing thoracic and lumbar spinal procedures. This
modality acts by blocking the dorsal rami, which in-
nervates paraspinal muscles and vertebrae. Two recent
RCTs evaluating the role of erector spinae blocks in
elective lumbar procedures have reported reduced post-
operative opioid consumption, less pain in the acute
postoperative period, and better patient satisfaction as
compared with the control group.24,25
The erector spinae block is commonly done under
ultrasonography guidance either as a single shot or a
continuous infusion. After cleaning and draping the
area, a 21-gauge block needle is inserted and advanced
toward the transverse process in a craniocaudal direc-
tion. The correct positioning of the tip is confirmed by a
linear spread of the injected anesthetic solution between
the transverse process and the erector spinae muscle. The
anesthetic solution acts on the dorsal rami of exiting
spinal nerves in this plane. Most studies in the literature
have described a single shot of 10 to 20 mL of 0.25%
bupivacaine/levobupivacaine or 0.2% ropivacaine as the
agent of choice. A higher volume of local anesthetic en-
sures more craniocaudal spread of the drug in a plane
deep to the erector spinae muscles and superficial to the
transverse process and intertransverse ligament,
whereas a higher concentration leads to deeper penetra-
tion in the paraspinal region.
Thoracolumbar Interfascial Plane Block
Thoracolumbar interfascial plane (TLIP) block was
described first by Hand et al26 in 2015, targeting the
dorsal rami and its branches exclusively in the lumbar
spine. The TLIP block involves injecting a long-acting
local anesthetic between the multifidus and longissimus
muscle planes aiming to block the branches of the dorsal
rami as they traverse the intermuscular plane. The
technique has several theoretical advantages over
the erector spinae block. Researchers have argued that
the anesthetic medication in an erector spinae block is at
the risk of being washed away because it is injected in
the surgical plane that is usually exposed during sur-
gery.26 In addition, as opposed to the erector spinae
block, this block does not interfere with neuro-
monitoring or postoperative neurological examination
because the ventral rami is relatively spared, and pa-
tients can be discharged on the same day because their
motor function stays intact.
A 21-gauge or 22-gauge echogenic needle is inserted
in a lateral-to-medial direction and passed through the
longissimus under ultrasonography guidance tillit reaches
the longissimus-multifidus plane where a local anesthetic
is injected. Bilateral blocks achieve complete analgesia up
to two to three levels craniocaudally from the level of
injection.26 Despite the claimed theoretical advantages,
better studies of high-quality evidence are needed to
establish the safety and efficacy of the TLIP block.
Multifidus Cervices Plane Block
The multifidus cervices plane block is similar to the TLIP
block for analgesia in the cervical region. This technique
includes injecting a long-acting local anesthetic in the
fascial plane between multifidus cervices and semi-
spinalis cervices at the level of the C5 spinous process
under ultrasonography guidance. The choice of anes-
thetic is bupivacaine or ropivacaine. The anesthetic agent
targets the branches of the dorsal rami of cervical nerves
traversing in the intermuscular plane. This technique has
shown promising early results in providing effective
perioperative analgesia in patients undergoing cervical
laminoplasty.27 Additional high-quality studies are
warranted to compare the outcomes of this block with
preexisting analgesia techniques.
Superficial Cervical Plexus Block
Superficial cervical plexus block provides site-specific
analgesia and is currently under evaluation for its role
as a part of the multimodal treatment plan to mitigate pain
in a setting of anterior cervical spine surgery. The cervical
plexus is constituted by the anterior rami of the upper four
cervical nerves and lies deep to the prevertebral fascia on
scalenus medius. The technique involves infiltrating a
long-acting local anesthetic at the punctum nervosum,
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therefore anesthetizing the lesser occipital, the great
auricular, the transverse cervical, and the supraclavicular
nerves.28 The clinician places the ultrasonography probe
centered over the posterior edge of sternocleidomastoid
after induction. Furthermore, the cervical plexus is
identified through the interscalene groove, and about
15 mL of solution is injected. This provides ipsilateral
anesthesia to the cape region over the anterior and lateral
aspects of the neck. A single-center RCT comparing GA
with awake cervical spine fusion with bilateral deep and
superficial cervical plexus blocks reported a trend toward
better postoperative pain control in the cervical plexus
block group.29
Transversus Abdominis Plane Block
The transversus abdominis plane (TAP) is a potential
space between transversus abdominis and internal obli-
que, and the field block achieved by infiltrating the local
anestheticinthatplaneiscalledtheTAPblock.30 The TAP
block is currently being used as a part of the multimodal
pain management strategy for anterior and lateral lumbar
fusion procedures (ALIF and LLIF). In a recent retro-
spective comparative study, patients undergoing
ALIF/LLIF with TAP block demonstrated shorter length
of stay, less postoperative nausea/vomiting, and lower
opioid consumption in the postanesthesia care unit as
compared with ALIF/LLIF patients without TAP block.31
However, larger RCTs are imperative to establish the
safety and efficacy of TAP blocks.
Indications and Contraindications
Absolute contraindications for spinal anesthesia are
well described in the literature and include the pres-
ence of any bleeding disorders, dermatological in-
fections, hypovolemia, and hypotension. In addition,
for effective anesthesia, an important prerequisite is
adequate spread of the anesthetic drug in the epidural
space. Severe lumbar stenosis seen as complete or
near-complete myelographic block acts as a hindrance
in the free spread of the drug in the epidural space and,
hence, may be a relative contraindication to regional
anesthesia. Failed back syndrome or radiological
demonstration of arachnoiditis is another important
radiological contraindication because of unreliable
spread of anesthetic agents.9 Several factors deter-
mine the relative success of regional anesthesia in a
spinal procedure including the surgical duration,
anticipated blood loss, level of surgery, and patient-
surgeon preference. General anesthesia is preferable
for surgeries with duration more than 3 hours and
more anticipated blood loss such as multiple-level
laminectomies or fusion.
An important indication for regional anesthesia in
spinal procedures, such as diskectomy and laminectomy,
is pregnancy. The procedure can be conducted safely in
the lateral position and is safer than general anesthesia
because it mitigates complications such as difficult intu-
bation or placental transfer of drugs. In patients with a
level of pathology proximal to T10, regional anesthesia is
avoided to prevent hemodynamic and ventilatory
depression. Finally, general anesthesia is the modality of
choice in obese individuals in view of poor pulmonary
volume reserve and compromised respiratory ability in
the prone position.
Regional Versus General Anesthesia:
Comparative Benefits
Regional anesthesia offers several advantages over gen-
eral anesthesia for orthopaedic surgeries. The reported
benefits include lower PONV, better postoperative
analgesia, decreased intraoperative blood loss, and better
hemodynamic profile and a blunted stress response.
Apart from these advantages, the risks associated with a
prone position such as corneal abrasions, brachial plexus
injuries, and positional neck and shoulder pain are also
reduced because an awake patient is able to protect
themselves better while positioning.
Regional modalities have been reported to markedly
reduce the postoperative opioid requirement and opioid-
related complications.17 Regional anesthesia is associ-
ated with a lower incidence of PONV as compared with
general anesthesia. This further leads to less postoper-
ative discomfort because nausea and vomiting is
associated with spasmic contraction of the spinal and
abdominal musculature. A recent review reported
reduced PONV associated with regional anesthesia in
five of eight studies included in the review.32
Regional anesthesia is associated with less intra-
operative blood loss as compared with general anes-
thesia. Several factors may be responsible for this.
Sympathetic blockade leading to vasodilatation in lower
extremities may be responsible for less intraoperative
bleeding. In addition, spontaneous breathing in regional
anesthesia leading to lower intrathoracic pressure and
dilatation of epidural veins may also be responsible for
less blood loss. Furthermore, regional anesthesia is also
associated with a favorable hemodynamic outcome pri-
marily governed by a lower heart rate and mean arterial
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pressure and smaller changes in these variables in intra-
operative and immediate postoperative periods.1,2,9,10,32
Other advantages with regional anesthesia include a
lower risk of thromboembolic complications, less post-
anesthesia care unit and hospital stay, along with a faster
food intake resulting in better patient and doctor satis-
faction rates.33
A few studies have reported contrasting findings to the
popular opinion. A study by Sadrolsadat et al, contrary
to their peers, found better satisfaction rates and lower
blood loss with general anesthesia as compared with
regional anesthesia. In this study, the incidence of
hypertension during recovery from anesthesia was also
higher in general anesthesia.10
Regional Anesthesia: Complications
Regional anesthesia is generally a safe modality. Never-
theless, it has a small risk of complications, which need
emphasis. Less serious but more common complications
include allergy, urinary retention in the postoperative
phase, bowel disturbance, and respiratory suppression.
More troublesome complications associated with
modalities of regional anesthesia include failure of
anesthesia regarding the depth, level or duration, or new-
onset neurological deficit in the postoperative period.
An important reason for the avoidance of regional
anesthesia in spinal surgery is its failure rate. The failure
rate with regional anesthesia needing a repeat procedure
has been reported to be as high as 4% in the literature.34
Failure can be attributed to several reasons such as
improper technique, complex anatomy because of pre-
existing spinal pathology, inadequate anesthesia block-
ade, or inability of the patient to tolerate the prone
position. Failure in the preoperative stage can be mitigated
by resorting to general endotracheal anesthesia. However,
intraoperative failure of regional anesthesia may warrant
intrathecal injection of local anesthetics, securing endo-
tracheal airway in the prone position or abandoning the
procedure and turning the patient supine to convert to
general anesthesia. Failure rates can be reduced with
proper patient selection and counseling with an intent to
settle their apprehensions. A proper three-way commu-
nication between the patient, the surgeon, and the anes-
thetist is crucial for the success of the procedure.
Hypotension after the administration of spinal or
epidural anesthesia is a commonly encountered event due
to sympathetic blockade, leading to vasodilation and
peripheral pooling of blood. Although a drop in blood
pressure needs intraoperative monitoring and fluid
loading before the administration of regional anesthetic,
it does not affect the overall outcome of the procedure.
Regional anesthesia is an unfamiliar modality of
anesthesia for spinal surgeons because of several
surgeon-specific concerns such as the effect on neuro-
monitoring signals; catheters in or near to the surgical
field; unpredictable length, depth, and level of anesthesia;
and inability to conduct a neurological examination in
the immediate postoperative period. Longer total anes-
thesia time is another concern for regional anesthesia,
especially in epidural or combined spinal-epidural anes-
thesia. However, a number of articles in the literature
have reported comparable anesthesia time for regional
and general anesthesia.35
A number of case reports of acute cauda equina syn-
drome have been reported in patients receiving neuraxial
anesthesia. Despite several case reports, the overall inci-
dence of this serious complication is very low. The
reported incidence is highly variable and ranges from
0.00085% to 0.2%.36 In the context of spine surgery,
this complication holds a major significance because the
cause for the same can be either surgical or related to
neuraxial anesthesia. Severe lumbar canal stenosis is an
important risk factor for the development of postoper-
ative neurological deficit and should be ruled out when
planning neuraxial anesthesia.
Applications of Regional Anesthesia
Regional anesthesia plays an instrumental role in the
success of the recent concepts such as awake spinal
fusion, outpatient spine surgery, and enhanced recovery
after spine surgery by reducing in-hospital duration and
postoperative pain and ensuring early rehabilitation.
Awake Spinal Fusion
“Awake spinal fusion” is a novel approach that com-
bines modern anesthetic techniques including regional
anesthetic techniques with advancements in surgical
techniques resulting in improved patient satisfaction
and overall outcomes. Along with techniques of regional
anesthesia, minimally invasive or endoscopic surgical
techniques are used for decompression supplemented by
percutaneous fixation techniques to minimize surgical
dissection and blood loss. It is a relatively new concept
with limited supporting evidence till date. Nevertheless,
it may prove to be highly effective in reducing postop-
erative hospital stays, in-hospital complications, and
cost of surgery while at the same time expediting
recovery and rehabilitation.37,38
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Outpatient Spine Surgery
Outpatient surgery occurs when the patient is dis-
charged on the day of surgery without being admitted
to the hospital.5 Multimodal pain management pro-
tocols comprising novel techniques of regional
anesthesia and analgesia along with recent advances
in surgical techniques such as percutaneous
and minimally invasive instrumentation systems have
played an instrumental role in making outpatient
spine surgery a feasible option. Apart from playing a
notable role in improving patient satisfaction and
outcomes, outpatient spine surgery is also beneficial
in checking the ever-increasing healthcare costs and
surgeon shortage in today’s era.39 Furthermore,
owing to the repeated surge of COVID-19 cases and
unprecedented staffing shortages nationwide, there
has been a rolling halt to elective inpatient surgeries
and need for a faster patient turnover. Considering
this need of the hour, several spinal procedures are
now being done in ambulatory surgical centers.
Best et al investigated changes in trends of outpatient
spine surgery for common spinal disorders and reported
an increase in the number of procedures by 540% for
intervertebral disk disorders and 926% for spinal ste-
nosis from 1994 to 2006. Canal stenosis, prolapsed
intervertebral disk, or disk degeneration are common
indications for which outpatient spine surgery is com-
monly done at our institute.
Enhanced Recovery After Spine Surgery
Regional modalities of anesthesia have also played an
instrumental role in the recent concept of enhanced
recovery after surgery (ERAS) protocols for spine sur-
gery. ERAS is a holistic perioperative protocol formu-
lated by using preexisting scientific evidence aimed
at minimizing morbidity and complications and maxi-
mizing the benefits derived of the intervention. Grasu
et al7 reported better pain scores and decreased opioid
consumption in the post-ERAS group when compared
with the pre-ERAS group in patients undergoing spine
surgery for metastatic spine disease. The authors pub-
lished their experience with implementation of ERAS for
one-level to three-level elective lumbar spine fusion at
their institution and reported shorter length of stay and
postoperative pain and functional outcome scores when
compared with pre-ERAS outcomes.40
Author’s Preferred Treatment
Spine surgery has seen a paradigm shift to outpatient or
ambulatory spine surgery over the past decade. The
most important factor contributing to this shift is the
better understanding of pain mechanisms and utilization
of multimodal analgesia for pain management. Multi-
modal analgesia in the current scenario encompasses
preoperative patient education and preemptive analge-
sia, intraoperative anesthesia, and postoperative
Figure 1
Diagram showing authors’ preferred regional anesthesia protocol. IV = intravenous, PACU = postanesthesia care unit, TLIP =
thoracolumbar interfascial plane.
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analgesia. The authors started using regional anesthesia
initially for decompressive laminectomies and dis-
kectomies. The availability of liposomal bupivacaine
and experience with the technique have expanded the
indications for regional anesthesia at the authors’
institution including one-level and two-level lumbar
spinal fusion using minimally invasive decompression
and percutaneous fixation techniques. A brief overview
of the author’s preferred protocol is shown in Figure 1.
Preoperative Period
A successful preemptive analgesia comprises successful
management of preoperative pain and blocking of the sub-
sequent nociceptive stimulus during intraoperative and
postoperativeperiods.Severalauthorshavereportedtheuse
of various permutations of NSAIDs, acetaminophen, neu-
romodulators such as gabapentin and pregabalin, oxy-
codone, and regional blocks in the preoperative period and
demonstrated lesser postoperative pain and opioid use.41,42
The authors prefer routine administration of 10 to 20 mg
of oxycodone and a TLIP/erector spinae block under mild
sedation with midazolam in the preoperative holding area
as a part of preemptive analgesia. For laminectomy, 20 mL
of 0.5% bupivacaine is normally administered on each
side, whereas for spinal fusion, 10 mL of 1.3% liposomal
bupivacaine is also administered in addition to normal
bupivacaine.
Intraoperative Period
Regional techniques of intraoperative anesthesia when
compared with general anesthesia have been found to
have lesser postoperative pain scores.17,43 Further-
more, several studies have shown reduced need for
postoperative narcotics by the administration of local
anesthetic solution subcutaneously around the incision
site just before the incision and closure.44 Other pro-
tocols recommend the use of ketamine at the time of
induction or infusion and fentanyl titrated to the
clinical effect. For surgical anesthesia, the authors
prefer spinal anesthesia with 1 to 2 mL of 0.5%
bupivacaine with 20 mg of fentanyl, along with mild
sedation with midazolam. Intraoperatively, music
therapy plays an important role in awake surgeries to
keep the patient calm and cooperative.
Postoperative Period
In a multimodal approach to manage postoperative pain,
several authors have recommended the use of postoper-
ative infiltration of local anesthetic and regional blocks.
Recent introduction of liposomal bupivacaine has also
allowed sustained drug release and pain control over
several days.45 Postoperative combination of oxy-
codone, cyclobenzaprine, acetaminophen, or tramadol
is usually used based on the institutional protocol. One
gram of IV acetaminophen, 2.5 mg of Valium, and 10 to
20 mg of oxycodone are administered for pain relief.
Most patients are mobilized and discharged the same or
the next day.
Summary
Regional anesthesia is an underutilized but safe and
effective alternative to general endotracheal anesthesia
for lower thoracic and lumbar cases. Regional modalities
of anesthesia, combined with the recent advancements in
spinal instrumentation, have led to rapid recovery, early
ambulation, and lesser opioid use in the postoperative
period. These improvements in the outcomes have made
lumbar disk and fusion surgeries possible on an outpa-
tient basis. Although regional anesthesia has a few con-
cerns and potential complications, they can be avoided
by proper patient and case selection and proper patient
counseling. The currently available literature lacks
studies analyzing long-term outcomes of regional anes-
thesia in spine surgeries. Well-planned studies with larger
sample size are warranted to evaluate other complica-
tions and long-term clinical outcomes for patients
undergoing regional anesthesia for spine surgery.
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