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International Journal of Research in Orthopaedics | November-December 2022 | Vol 8 | Issue 6 Page 649
International Journal of Research in Orthopaedics
Rangnekar A et al. Int J Res Orthop. 2022 Nov;8(6):649-654
http://www.ijoro.org
Original Research Article
Awake spinal fusion: a retrospective analysis of minimal invasive single
level transforaminal lumbar interbody fusion done under spinal
anaesthesia in 150 cases
Ameya Rangnekar, Mani K. Anand*, Praveen Goparaju, Amit Chugh,
Abhijith Shetty, Saijyot Raut, Vishal Kundnani
INTRODUCTION
The number of spinal fusion surgeries has seen a great
surge in recent few decades owing to longevity and
increased prevalence of degenerative pathology in
elderly.1 Cloward introduced technique of posterior
lumbar interbody fusion (PLIF) using a spinous process
autograft. Given the high pseudoarthrosis rate with stand
alone grafts, the PLIF technique was augmented with
instrumented fixation utilizing the Harrington rods in the
1950s, later, the Hartshill rectangle, and finally the
pedicle screws.2 Transforaminal lumbar interbody fusion
ABSTRACT
Background: Spinal anaesthesia carries the advantage of having rapid onset, lesser blood loss, early recovery and
hospital stay as compared to general anaesthesia. The present study evaluated outcomes of awake spinal fusion i.e.,
minimal invasive single level transforaminal lumbar interbody fusion (MIS-TLIF) under spinal anaesthesia. Current
study is a retrospective analysis of prospectively collected data carried to assess patient related outcome benefits for a
single level transforaminal lumbar interbody fusion done under spinal anaesthesia.
Methods: Patients who fit deemed criteria not responding to 6 weeks of conservative treatment to lumbar
degenerative pathologies underwent MIS-TLIF. The demographic data, visual analogue pain scale (VAS), Oswestry
disability index (ODI), blood loss, time from entering operation theatre to time of incision, time of bandaging to exit
from operation theatre, time of stay in post anaesthesia care unit (PACU), duration of surgery, nausea/vomiting,
urinary retention, requirement of analgesics, duration of stay in hospital, peri-operative complications, fusion rate and
satisfaction score were compiled and assessed.
Results: 150 patients were operated with MISTLIF under spinal anaesthesia. VAS and ODI score improved
significantly at final follow up (p<0.05). The mean duration of surgery was 148±18.24 minutes and blood loss were
109.64±110.45 ml. The average time from entering OT to incision and bandaging to exit was respectively 27.32±8.44
and 6.43±3.28 minutes. Mean PACU time was 36.74±6.32 minutes while duration of stay averaged 1.58±0.67 days.
Post operative analgesia requirement was in 10.6% patients and radiographic fusion was observed in 96.6% patients.
90.6% patients were fully satisfied with spinal anaesthesia.
Conclusions: Awake spinal fusion should be considered as a novel surgical approach with newer minimal invasive
surgical techniques and regional anaesthesia to improve patient satisfaction and overall surgical outcome.
Keywords: Spinal anaesthesia, Spinal fusion, TLIF, ODI, VAS, MIS TLIF
Department of Orthopaedics, Bombay Hospital, Mumbai, Maharashtra, India
Received: 07 August 2022
Revised: 07 September 2022
Accepted: 08 September 2022
*Correspondence:
Dr. Mani K. Anand,
E-mail: manikant.mann@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: https://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20222702
Rangnekar A et al. Int J Res Orthop. 2022 Nov;8(6):649-654
International Journal of Research in Orthopaedics | November-December 2022 | Vol 8 | Issue 6 Page 650
(TLIF), a posterolateral approach to lumbar fusion was
initially described in 1982 by Harms and Rollinger which
gained popularity in 1992 after work by Harms and
Jeszenszky.3,4 Unlike PLIF this technique reduces chance
of injury to neural structures but involves significant
muscle retraction and dissection. Open TLIF procedure
carries the disadvantage of iatrogenic soft tissue and
muscle injury and hence novel surgical technique of
minimal invasive transforaminal lumbar interbody fusion
by use of serial tubular dilators and muscle retracting
approach was introduced by Foley et al in early 2005
which has now become more and more popular. Lumbar
spinal fusion can be carried out in general as well as
spinal anaesthesia.6 Of these, general anaesthesia is most
commonly preferred as it offers the advantage of secured
airway in prone position.7,8 On the other hand, spinal
anaesthesia gives advantages to reposition the patient
during surgery and avoid compression injuries in-addition
to better neurocognitive dysfunction, reduces pulmonary
complications and improves postoperative analgesia with
reduced pain killer and antiemetic requirement apart from
mitigating the need and side effects of reversal
medication associated with general anaesthesia.9-11
Fewer studies have been done to compare spinal
anaesthesia versus general anaesthesia in spine surgeries.
Studies have implicated shorter surgical time, less time in
recovery room, lesser incidence of urinary retention,
postoperative pain, nausea-vomiting and most
importantly less financial implications in spinal
anesthesia.12,13 The increased rate of fusion surgeries with
minimal invasive technique has brought major
improvements in techniques of surgery, anaesthetic
procedures and rehabilitation protocols, aimed at limiting
the post-operative hospital stay and early return to
work.14 Spinal Anaesthesia with added advantages and
reduced post operative issues is an addition to safety of
spine surgery in single level minimal invasive spine
surgeries. Also awake fusion has been a recent upgrade in
spine surgery with better neurocognitive functions post
operatively compared to general anaesthesia. Despite
encouraging results with spinal anaesthesia, the literature
evaluating efficacy of spinal anaesthesia in lumbar fusion
surgeries is scanty. This study intends to evaluate the
safety, efficacy and techniques with advantages of spinal
anaesthesia as an alternative option to general anaesthesia
in minimal invasive transforaminal lumbar interbody
fusion surgery for symptomatic lower lumbar pathologies
requiring fusion.
METHODS
Our study was retrospective analysis of prospectively
collected data of 150 patients who underwent single level
minimally invasive transforaminal lumbar interbody
fusion at a single institute (Bombay hospital and medical
research centre, Mumbai) by a senior spine surgeon from
March 2015 to March 2017. Patient inclusion and
exclusion criteria were laid stringently and same clinical
pre operative and post operative protocols were followed
for patient selection, surgery and post op rehabilitation.
Inclusion criteria
Inclusion criteria were; patients with symptomatic lumbar
pathology (mechanical low back pain and radiculopathy,
claudication with or without neuro-deficit) at level L3-
4/L4-5/L5-S1 due to various etiologies (degenerative/
dysplastic/isthmic-spondylolisthesis, degenerative lumbar
canal stenosis with instability, prolapsed intervertebral
disc) with follow up of minimum two years.
Exclusion criteria
Exclusion criteria were; patients requiring revision spine
surgery, having infection, tumour or other pathological
causes, extraspinal cause of back pain / radiculopathy,
requiring multi-level surgery, requiring surgery at higher
lumbar levels i.e. L1-L2 or L2-L3 levels, severe co-
morbidities like cardiac dysfunction or short follow up.
All surgeries were managed by a single anaesthesiologist
with similar anaesthetic technique. Demographic
characteristics and American society of
anaesthesiologists (ASA) physical status of the patients
were all noted. According to the inclusion and exclusion
criteria, those included were counselled for surgery. The
patients who fit the deemed criteria for study were
offered both choices to choose either spinal or general
anaesthesia. They were thoroughly counselled and
explained pros and cons associated with each technique
and allowed to opt anaesthesia as per their choice. The
choice of anaesthesia was chosen by the patient and not
observer of the study. 150 patients who opted for spinal
anaesthesia gave consent and satisfied the selection
criteria.
Anaesthesia technique
Spinal anaesthesia administered patients were first given
a half a litre infusion of ringer lactate solution 20 minutes
before giving spinal anaesthesia. After entering operating
room patient was seated. Local infiltration of 2.5 ml of
2% lidocaine was given, SA was achieved via lumbar
puncture, using a needle size of 25 gauze most
commonly.
On visualization of cerebrospinal fluid, bupivacaine was
injected combined with fentanyl into the intrathecal
space. Bupivacaine was given as 15 mg dose of a 0.75%
bupivacaine in 8.25% dextrose solution. 25 µg of fentanyl
was given in combination with bupivacaine, in order to
increase the spinal anaesthesia antinociceptive effect.
Once the spinal anaesthesia was administered, adequate
anaesthesia was verified on the lower back and
extremities after the patient was put into a supine
position. The patient was then turned into the prone
position on the operating table. Oxygen was administered
by nasal cannula and vitals monitored throughout the
procedure.
Rangnekar A et al. Int J Res Orthop. 2022 Nov;8(6):649-654
International Journal of Research in Orthopaedics | November-December 2022 | Vol 8 | Issue 6 Page 651
Operative technique
Patients who underwent MISTLIF were approached with
a 2.5 cm incision paramedian 3-5 cm from midline on the
more symptomatic side. Tubular decompression with 22
mm tubes (METRx system, Medtronics) with partial
unilateral laminotomy and inferior facetectomy was done
under microscopic guidance. It was followed by
discectomy, end plate preparation and insertion n of cage
with locally obtained autograft. Cannulated pedicle
screws were inserted after placement of guidewire
through cook’s needle and serial tapping over dilators and
tap under fluoroscopy guidance. Placement of screw was
done using same incision on ipsilateral side while two
1cm incisions on contralateral side. Rod was introduced
with a device through a separate proximal stab incision.
After placement of locking-cap screws through the screw
extenders and later compression, the screws were torqued
and the screw extenders were removed. Thorough wash
was given followed by closure in layers. At completion of
the procedure and the patient was transferred to the
PACU for the recovery.
The patients remained in the post anaesthesia care unit
(PACU) till hemodynamic stability was confirmed which
was followed by transfer to the ward. Comprehensive
demographic, clinical and radiological parameters were
documented including age, gender, duration of
symptoms, indication of surgery, pathology (large central
disc herniation, facetal arthritis, spondylolisthesis), level
of surgery, medical co-morbidities, BMI and presence of
cardiopulmonary co-morbid conditions was documented.
Pain and disability were assessed pre-operatively, post
operatively and at final follow up using visual analog
score and Oswestry disability index at sequential follow
up. Fusion was assessed using Bridwell criteria at final
follow up. Peri-operative parameters including duration
of surgery, blood loss during surgery, time from entering
OT to incision, CSF leak intraoperative with dural
tear/dural needle prick, bandaging to exit time,
requirement of post operative analgesia, post operative
emesis episodes, urinary retention, PACU time, duration
of stay in hospital were documented and data was
extrapolated to assess results. Post operative
complications were documented in general and
neurological category and included general complications
(fever, wound infection, cardiac /pulmonary issues, UTI),
neurological (CSF leak post operatively and neurological
deficit). Study approval from the Institutional review
board and Ethics committee was taken with informed
patient consent. Statistical Analysis was done using
independent samples test and comparison of proportions
was done using Pearson Chi-square test. A p value of
<0.05 was taken as statistically significant.
RESULTS
Total 150 patients were included in the study undergoing
MIS TLIF under spinal anaesthesia during the study
period. The majority of patients were over 40 years in
90% of total patients studied. The mean follow-up period
was 28.6 months. There was no conversion from MIS-
TLIF to open TLIF. The average age of patients was
found to be 58.06±9.46 years. There was female
predominance in group with 62% patients were female
and 38% male. (Table 1).
Table 1: Demographic data (n=150).
Parameter
Spinal anesthesia
Age (mean±SD) years
58.06±9.46
Gender N (%)
Female
93 (62)
Male
57 (38)
BMI (kg/m2)
28.32±2.5
Comorbidities
Single
82
Two or more
37
Duration of symptoms
(months)
8.6±7.8
Mean follow up duration
(months)
28.6±4.5
Table 2: Clinical parameters (n=150).
Parameter
Spinal anesthesia
N (%)
Level of surgery
L3-L4
13 (8.8)
L4-L5
88 (58.6)
L5-S1
49 (32.6)
Indication for surgery
Degenerative
79 (52.7)
Isthmic
26 (17.3)
LCS with instability
34 (22.7)
PIVD
11 (7.3)
Duration of surgery (±SD)
(minutes)
148±18.24
Blood loss (±SD) (ml)
109.64±110.45
Time of entering OT to
incision (minutes)
27.32±8.44
Time from bandaging to
exit (minutes)
6.43±3.28
Post anaesthesia care unit
(PACU) (minutes)
36.74±6.32
Immediate post operative
requirement of analgesia
(within 4 hours after
surgery)
16 (10.6)
Hospital stay (days)
1.58±0.67
Solid radiographic fusion
96.6
Satisfaction score
Fully satisfied
90.6
Partially satisfied
8.6
Unsatisfied
0.8
The mean BMI of study population was 28.32±2.5 kg/m2
while the average duration of symptoms was 8.6±7.8
Rangnekar A et al. Int J Res Orthop. 2022 Nov;8(6):649-654
International Journal of Research in Orthopaedics | November-December 2022 | Vol 8 | Issue 6 Page 652
months. Amongst our study population 82 patients out of
150 had one co-morbidity while 37 patients had two or
more co-morbidities. The indication for surgery in our
study were degenerative, isthmic, lumbar canal stenosis
with instability and prolapse of intervertebral disc and
majority of the patients underwent surgery due to
degeneration (52.66%).
Table 3: VAS and ODI score.
Parameters
Pre-
operative
Final
follow up
P value
ODI
7.67±1.24
3.23±1.02
0.043
VAS
73.26±1.16
18.84±6.08
0.031
The most common level of surgery performed was at L4-
L5 in 58.6% of patients followed by L5-S1 in 32.6%
patients (Table 2). The mean duration of surgery was
148±18.24 minutes whereas the mean blood loss was
109.64±110.45 ml. The extent of spinal anaesthesia
obtained was up to D8 level in majority of cases. The
mean PACU time was 36.74±6.32 minutes and average
hospital stay was 1.58±0.67 days. The effect of analgesia
post operative was not required in most of the cases upto
4 hours. 10.6% patients required injectable pain killer
within 8 hours after surgery. Significant improvement
was observed in VAS and ODI scores at any time-point
of follow-up when compared with the preoperative
condition (p<0.05). Serial scoring was done
preoperatively, post operatively at 7 days, 3 months, 6
months, 1 year and final follow up (Table 3). The
incidence of nausea, vomiting was seen in 6.6% of
patients while that of urinary retention was seen in 8.6%
patients. The other complications encountered in our
study were screw malposition, dural tear, screw
loosening, cage slippage and implant failure seen in very
less number (Table 4).
Table 4: Peri-operative and post-operative
complications (n=150).
Parameter
Spinal
anesthesia
N (%)
Screw malposition
1 (1.1)
Dural puncture/tear
7 (4.6)
Screw loosening
4 (2.6)
Cage slippage
1 (1.1)
Implant failure
1 (1.1)
Nausea/vomiting
10 (6.6)
Urinary retention
19 (8.6)
Fever
4 (2.6)
Wound infection
3 (3.1)
Post operative CSF leak
0 (0)
Post operative neurological deficit
1 (1.1)
Post operative newly onset
Paresthesia
2 (1.3)
Cardiopulmonary complications
0 (0)
UTI
1 (1.1)
Post operative neurological deficit (EHL 4/5) was seen in
one of the patients while post operative new onset
paraesthesia was seen in 2 patients. The mean time from
entry of patient inside operation theatre to induction was
27.32±8.44 mintues and time of bandaging to exit from
operation theatre was 6.43±3.28 minutes. Solid
radiographic fusion (Bridwell 1 and 2) was achieved in
96.6% of patients. 90.6% of patients were satisfied, 8.6%
were partially satisfied and 0.8% were unsatisfied.
Patients who reported no pain, no nausea, no vomiting,
and no headache were considered satisfied. Those who
reported one or more of them were considered partially
satisfied while those who reported all of them were
considered unsatisfied with spinal anesthesia.16
DISCUSSION
Despite all the encouraging results of spinal anaesthesia
over general anaesthesia, there is lot of lacunae in
literature and studies to prove its efficacy and
perioperative outcomes. ‘awake spinal fusion’ i.e. lumbar
spine fusion under regional anaesthesia employs minimal
invasive technique. Our study emphasizes awake spinal
fusion under conscious sedation which can be efficiently
done in a non-endoscopic minimal invasive technique
through tubular retractors with bupivacaine for longer
duration surgeries over 2 hours.17
In contrast to conventional TLIF, the minimal invasive
(MIS TLIF) comes with the advantage of decreased pain,
early ambulation, early discharge from the hospital.18 In
alignment to the above benefits, use of regional
anaesthesia drugs come with lot of advantages. It avoids
incidences of nausea-vomiting, transient neurocognitive
dysfunction arising as a result of general anaesthesia.19
Although patients with haemodynamic instability and
cardiac dysfunction are contraindicated to spinal
procedures. In the present study, the preoperative VAS
and ODI score was significantly improved post
operatively at 7 days, 3 months, 6 months, 1 year and at
final follow up (p<0.05). The findings in study done by
Patel et al, Wang et al also showed significant difference
in preoperative and post operative VAS and ODI score in
MIS TLIF done under general anaesthesia. It implied that
the pain outcome of MISTLIF was independent of choice
of anaesthesia.20,21 Mean blood loss reported in our study
was 109.64±110.45 ml whereas, Habib et al recorded
mean blood loss of 163 ml in MIS TLIF versus 366.8 ml
in open TLIF. Schwender et al in his study reported
estimated blood loss of 140ml done in general
anaesthesia.22,23 It shows blood loss was relatively less in
patients undergoing MIS TLIF in spinal anaesthesia.
Although the exact cause could not be known but relative
hypotension achieved during spinal anaesthesia may play
a contributory role. In our study, mean duration of
surgery was 148±18.24 minutes which is comparable to
the results found by Jhala et al and Patel et al.18,20 It
implied that the total duration of surgery was independent
of type of anaesthesia. Though the duration of surgery is
a large component of operative time parameter, we
Rangnekar A et al. Int J Res Orthop. 2022 Nov;8(6):649-654
International Journal of Research in Orthopaedics | November-December 2022 | Vol 8 | Issue 6 Page 653
recorded two additional time landmarks, time from entry
into operation theatre to incision time and bandaging to
exit time. We found a significantly shorter operation
theatre to incision time and also time from bandaging to
the exit in our study group, which is comparable to study
done by Pierce et al.24 This highlighted higher efficiency
with quicker operation theatre turnover rates and cost
effectiveness. The shorter duration in spinal anaesthesia
was because of skip of general anaesthesia perioperative
events like pre-anaesthetic medication taking time to
prepare before induction and intubation as well as post-
operative anaesthesia reversal time.
The patients in our study group required lesser PACU
time as compared to Jellish et al where there was longer
PACU stay post-surgery. We observed a shorter hospital
stay 1.58±0.67 days similar to studies done by Garg
et al.14,25 Since this study was performed at lower lumbar
levels i.e. below L3, the chance of neuro-deficit was very
less. Also, author did not experience any event of neuro-
deficit in his period of study. Although general
anaesthesia offers the advantage of observation of motor
recovery soon after reversal of anaesthesia, a sensible
motor evaluation is difficult to obtain as patient is in
drowsy state. Spinal anaesthesia offered excellent control
of post operative pain which gave the advantage of early
shifting of patient from PACU to ward. The mean
hospital stay in our study was lesser as spinal anaesthesia
offered early ambulation, early start to oral feeds with
less throat irritation, early bowel function return and less
neurocognitive changes which favoured early discharge
from hospital.
The incidence of nausea- vomiting and urinary retention
was seen in 6.6% and 8.6% patients respectively. McLain
et al found a higher incidence of nausea in general
anaesthesia group, while reported a significantly lower
incidence of urinary retention in spinal anaesthesia
induced patients.9 Prolonged sensory loss and analgesia
after bupivacaine perhaps could be the reason of higher
incidence of urinary retention in patients. All those
patients who had urinary retention episode had temporary
retention and not permanent one. The patients with
retention problem were managed by inserting foley’s
catheter in situ and keeping it for 24 hours which was
later removed. Patients were discharged comfortably only
after urine was passed. Even though there were dural
puncture/tear in 4.6% of patients, there was no incidence
of CSF leak. No active intervention was done for dural
puncture. It was managed with water tight closure. Fall-
off of muscles after removal of tube leaving no dead
space possibly could be a reason for prevention of CSF
leak. One patient in our study had EHL weakness 4/5 and
two patients had post operative paraesthesia which was
managed conservatively under closed observation.
Symptoms fully recovered within 6 weeks. In our study,
radiographic fusion was achieved in 96.6% patients. The
results by Schwender et al was also comparable that had
fusion of almost 100% cases.23 We tried to quantify
satisfaction rate of patients who underwent MISTLIF in
spinal anaesthesia. 90.6% of patients were satisfied, 8.6%
were partially satisfied and 0.8% were unsatisfied from
the procedure. The criteria cites patients who reported no
pain, no nausea, no vomiting, and no headache were
considered satisfied. Those who reported one or more of
them were considered partially satisfied while those who
reported all of them were considered unsatisfied with
spinal anesthesia.16 Patients with pre-existing
apprehension may feel uncomfortable due to loud sounds
during orthopaedic procedures especially during
instrumentation. This may lead to intraoperative
haemodynamic variations to the patient, music therapy
has offered great benefits.26 Though it may seem that
spinal anaesthesia has certain advantages over general
anaesthesia but this method cannot be followed for all
patients. Loss of spinal anaesthesia effect can happen
although not reported in any of our patients. Another
disadvantage being time constraint, contraindications in
patients with morbid obesity, obstructive sleep apnoea
and cardiopulmonary dysfunction. Hence, patient
selection needs to be careful.
Limitations
Limitations of current study were; intraoperative
haemodynamic changes were not considered and this was
not compared to general anaesthesia group.
CONCLUSION
Awake spinal fusion technique is an excellent newer
addition to day care services. MIS TLIF done under
spinal anaesthesia offers less post operative pain, early
ambulation, return to work and hence reduced cost. It
offers operating room efficiency with reduced total
operative time with lesser stay in PACU. Hence, spinal
anaesthesia can be safely used as an alternative choice for
elective lower lumbar level fusion surgeries with
relatively lower adverse events.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
institutional ethics committee
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