Neurosurgery notes/Procedures/Awake spine surgery

Awake spine surgery

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Spinal procedure
  • Findings on Commonly Performed Awake Spine Surgeries
    • Laminectomy/Discectomy:
      • Spinal anaesthesia was associated with (when compared to general anaesthesia)
        • Shorter operation times
        • Less postoperative nausea
        • Lower rates of urinary retention
        • Spinal headache
        • Shorter hospital stays
        • Lower perioperative blood pressure
        • Lower heart rates
        • Reduced need for postoperative pain medication.
    • Anterior Cervical Discectomy and Fusion (ACDF):
      • Awake ACDF procedures are less common than their lumbar counterparts and have shown mixed outcomes.
      • While local anaesthesia can lead to less nausea and shorter recovery times, it has also been associated with higher intraoperative blood pressure and heart rate, as well as greater pain levels both during and after surgery.
      • Consequently, patient satisfaction was reported to be higher in the general anaesthesia group due to better pain control.
    • Lumbar Fusion:
      • A key advantage is the ability to receive direct feedback from the patient when operating near neural structures.
      • The authors note that it is difficult to draw firm conclusions on its success, as existing studies may have selected patients who were already predisposed to positive outcomes (e.g., those with low anaesthesia risk and good postoperative care).
    • Dorsal Column (DC) Stimulator Placement:
      • Performing this procedure on an awake patient allows the surgeon to receive real-time feedback to test affected nerves and ensure correct placement.
      • A major drawback is that spontaneous movements from the patient can displace the electrodes.
        • A significantly higher device failure rate in awake procedures (29.7%) compared to those done under general anaesthesia (14.9%).
  • Indications, Contraindications, and Patient Selection
    • Indications:
      • Awake surgery is a beneficial option for patients who cannot undergo general anaesthesia, such as the elderly or those with multiple comorbidities. It is also indicated for minimally invasive procedures where live neuro feedback can reduce the risk of nerve damage.
    • Contraindications:
      • Reasons to avoid awake surgery include patient refusal, coagulation disorders, or a nearby infection. It is also contraindicated for patients with a high risk of pulmonary complications (e.g., morbid obesity, COPD, sleep apnea), those under 15, or individuals who may become agitated during a long procedure. Procedures lasting over 90 minutes and patients with pre-existing anxiety are also generally unsuited for this technique.
    • Ideal Candidate:
      • The ideal patient for awake spine surgery would have a healthy BMI, no respiratory or pre-existing mental health issues like anxiety, and require a minimally invasive procedure on one or two spinal levels.
  • Advantages and Limitations
    • Advantages:
      • Elimination of risks associated with general anaesthesia, such as delirium and opioid use.
        • This leads to shorter hospital stays, reduced costs, lower risk of surgical site infections, and higher patient satisfaction.
      • Real-time neural feedback from the patient.
    • Limitations:
      • Local anaesthesia has a limited duration of action, restricting the operating time and the complexity of the procedures that can be performed.
      • Risks associated with spinal anaesthesia itself, such as CSF leaks and infection.
      • Furthermore, being conscious during surgery can cause significant anxiety for some patients.