Awake spine surgery is a promising option for appropriately selected cases

Awake spine surgery has been increasingly adopted in orthopaedic and neurosurgical practices. The approach employs regional anesthesia techniques — primarily spinal or epidural anesthesia — sometimes supplemented by peripheral nerve blocks and mild sedation. This can help patients avoid risks and side effects associated with general anesthesia. This article synthesizes findings from recent systematic reviews, meta-analyses, and discussion articles on awake spine surgery, focusing on comparative outcomes.

The principle behind awake spine surgery is to perform surgical intervention on the spine with the patient awake, using spinal anesthesia to provide adequate analgesia and muscle relaxation. This anesthesia technique is widely employed in the arthroplasty world. This method is particularly advantageous for patients in whom general anesthesia poses a significant risk due to comorbidities.

There are several key advantages of spinal anesthesia in awake spine surgery. The first is reduced length of hospital stay. Awake procedures are also associated with decreased operative time and fewer complications. The overall complication rate, including postoperative nausea, vomiting, and urinary retention, is significantly lower in patients who receive spinal anesthesia.

Clinical implications
A comprehensive systematic review and meta-analysis by Rajjoub et al. published in the European Spine Journal assessed 38 studies including 7,820 patients. The meta-analysis revealed that awake patients had a mean difference of -0.40 days in hospital stay and approximately 20 minutes shorter operative time compared to those under general anesthesia. Moreover, the relative risk of overall complications was 0.59 (95% confidence interval, 0.47-0.74), in favor of spinal anesthesia.

Another contribution from researchers at Mayo Clinic outlines the paradigm shift that awake spinal surgery represents in neurosurgery, also demonstrating reduced OR time and diminished postoperative pain. Additional studies highlight that the use of spinal anesthesia is associated with reduced need for postoperative pain management and may help to decrease blood loss. Direct patient communication during awake spine surgery with spinal anesthesia is also useful for monitoring general well-being and neurological status in unblocked regions, but of note cannot provide reliable assessment of the anesthetized surgical area.

Additional perspectives
As with any intervention, there are pros and cons. The time constraint of awake spine surgery may not allow its use. The procedure length is constrained by the duration of effective regional anesthesia, patient tolerance, and the complexity of the procedure, with most cases limited to one to three hours. Also, patients with BMI >35 or sleep apnea may not be candidates, as they are at higher risk of carbon dioxide accumulation. During awake spine surgery, patients are often positioned prone, which exacerbates the mechanical disadvantages of obesity by further reducing lung volumes and increasing airway collapsibility.

In addition, patient anxiety plays a large part in the feasibility of awake spine surgery. Some patients, such as those with claustrophobia, may not tolerate positioning.

Physicians must evaluate each patient’s unique clinical situation, including comorbidities and the complexity of the surgery. The selection of anesthetic technique should be individualized to enhance patient outcomes and optimize the use of healthcare resources.

Awake spine surgery offers an innovative approach to spinal healthcare, providing a promising alternative to traditional methods. The compelling evidence of reduced complication rates and shorter recovery periods advocates for its consideration in very select candidates. With the growing body of supportive literature, awake spine surgery is poised to become an emerging trend in spine surgery, enhancing patient care and healthcare efficiency.

Kyle W. Geiger, MD, is a fifth-year orthopaedic surgery resident at the University of Iowa. He plans to pursue a career in spine surgery after fellowship at the Leatherman Spine Fellowship Program.

References

1. Rajjoub R, Ghaith AK, El-Hajj VG, et al. Comparative outcomes of awake spine surgery under spinal versus general anesthesia: A comprehensive systematic review and meta-analysis. Eur Spine J. 2024;33(3):985-1000. doi:10.1007/s00586-023-08071-y
2. Mayo Clinic. Awake spinal surgery: A paradigm shift in neurosurgery. Medical Professionals: Neurology and Neurosurgery. April 23, 2022. Accessed Sept. 17, 2025. https://www.mayoclinic.org/medical-professionals/news/awake-spinal-surgery-a-paradigm-shift-in-neurosurgery/mac-20531255
3. Fiani B, Reardon T, Selvage J, et al. Awake spine surgery: An eye-opening movement. Surg Neurol Int. 2021;12:222. Published 2021 May 10. doi:10.25259/SNI_153_2021
4. Sykes DAW, Tabarestani TQ, Salven DS, et al. Awake spinal anesthesia facilitates spine surgery in poor surgical candidates: A case series. Neurochirurgie. 2023;69(3):101444. doi:10.1016/j.neuchi.2023.101444