Comparative outcomes of awake spine surgery under spinal versus general anesthesia: a comprehensive systematic review and meta-analysis

Background Awake surgery, under spinal anesthesia (SA), is an alternative to surgery under general anesthesia (GA), in neurological and spine surgery. In the literature, there seem to be some evidence supporting benefits associated with the use of this anesthetic modality, as compared to GA. Currently, there is a notable lack of updated and comprehensive review addressing the complications associated with both awake SA and GA in spine surgery. We hence aimed to perform a systematic review of the literature and meta-analysis on the topic. Methods A systematic search was conducted to identify studies that assessed SA in spine surgery from database inception to April 14, 2023, in PubMed, Medline, Embase, and Cochrane databases. Outcomes of interest included estimated blood loss, length of hospital stay, operative time, and overall complications. Meta-analysis was conducted using random effects models. Results In total, 38 studies that assessed 7820 patients were included. The majority of the operations that were treated with SA were single-level lumbar cases. Awake patients had significantly shorter lengths of hospital stay (Mean difference (MD): − 0.40 days; 95% CI − 0.64 to − 0.17) and operative time (MD: − 19.17 min; 95% CI − 29.68 to − 8.65) compared to patients under GA. The overall complication rate was significantly higher in patients under GA than SA (RR, 0.59 [95% CI 0.47–0.74]). Patients under GA had significantly higher rates of postoperative nausea/vomiting RR, 0.60 [95% CI 0.39–0.90]) and urinary retention (RR, 0.61 [95% CI 0.37–0.99]). Conclusions Patients undergoing awake spine surgery under SA had significantly shorter operations and hospital stays, and fewer rates of postoperative nausea and urinary retention as compared to GA. In summary, awake spine surgery offers a valid alternative to GA and added benefits in terms of postsurgical complications, while being associated with relatively low morbidity.