Clinical Neurology and Neurosurgery 119 (2014) 39–43

Contents lists available at ScienceDirect

Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

Review

Regional anesthesia versus general anesthesia for surgery on the

lumbar spine: A review of the modern literature夽
Joaquin O. De Rojas, Peter Syre, William C. Welch ∗
Department of Neurosurgery, University of Pennsylvania, Philadelphia, USA

a r t i c l e i n f o a b s t r a c t

Article history: Lumbar spine surgery can be performed using different anesthetic techniques such as general endotra-
Received 21 August 2013 cheal anesthesia (GA) or spinal-based regional anesthesia (RA). Several studies have been performed
Received in revised form comparing these two anesthetic techniques and have revealed disparate results. As such, we set out to
12 November 2013
review the relevant literature. We performed a literature search for clinical articles comparing cohorts of
Accepted 19 January 2014
Available online 27 January 2014
patients who underwent RA versus GA for lumbar spine surgeries. We compared results of these studies
between groups with respect to the following outcome variables: heart rate (HR), mean arterial pres-
sure (MAP), blood loss, duration of surgery, time spent in the PACU, post-operative analgesic use or pain
Keywords:
Lumbar scores, urinary retention rates, and nausea or anti-emetic requirements. Eleven studies were identified
Laminectomy that compared cohorts of patients who underwent GA or RA. Of these, 4 were randomized control trials,
Discectomy 3 were case control trials, 2 were prospective cohorts, and 2 retrospective analyses. Seven-out-of-seven
Spinal anesthesia studies reported reduced HRs and MAPs in the RA compared to GA group, and 7/9 studies reported a lower
General anesthesia incidence of post-operative analgesic requirement and/or decreased pain scores for the RA group. Our
review of the literature suggests that both RA and GA are safe and effective techniques for lumbar spine
surgery and that RA may prove a better alternative than GA for healthy patients undergoing simple lum-
bar decompression procedures or for patients who are at high risk for general anesthetic complications.

Published by Elsevier B.V.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.1. Literature review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.2. Hemodynamic status (heart rate, mean arterial pressure, and blood loss; Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.3. Surgery time (Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.4. PACU time (Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.5. Post-operative narcotic use and/or pain score (Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.6. Post-operative urinary retention (Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.7. Post-operative nausea (Table 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.1. Proposed mechanisms for favorable outcomes of RA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.2. When to not use RA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Abbreviations: GA, general endotracheal anesthesia; RA, regional anesthesia; post-op, post-operative; HR, heart rate; MAP, mean arterial pressure; PACU, post-operative
anesthesia care unit; VAS, visual analogue scale.
夽 Portions of this work were presented in abstract form/in poster form/as proceedings at the Pennsylvania Neurosurgical Society 99th Annual Scientific Meeting, Hershey,
PA, July 2012.
∗ Corresponding author at: Department of Neurosurgery, University of Pennsylvania, Department of Neurosurgery at Pennsylvania Hospital, Washington Square West
Building, 235 South 8th Street, Philadelphia, PA 19106, USA. Tel.: +1 215 829 6700; fax: +1 215 829 7895.
E-mail addresses: joaquind@mail.med.upenn.edu (J.O. De Rojas), William.welch@uphs.upenn.edu (W.C. Welch).

0303-8467/$ – see front matter. Published by Elsevier B.V.

http://dx.doi.org/10.1016/j.clineuro.2014.01.016
40 J.O. De Rojas et al. / Clinical Neurology and Neurosurgery 119 (2014) 39–43

5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

1. Introduction 2. Methods

Lumbar and lower thoracic spinal surgery can be safely per- Clinical studies in the English literature that described patients
formed under a variety of anesthetic techniques. These include undergoing either general or regional anesthesia for simple, lumbar
techniques such as general endotracheal anesthesia (GA) or a spine surgery were identified from electronic databases including
more “local” method paired with sedation that we will refer PubMed, Medline and EMBASE; Index Medicus; bibliographies of
to as regional anesthesia (RA), and which includes epidural pertinent articles; and expert consultation. Review of textbooks
anesthesia via catheter infusion and spinal anesthesia via injec- and the “Related Articles” feature of PubMed supplemented these
tion. The authors of a recent study comparing RA and GA searches. The search strategy included various medical subject
approaches [1] proposed that the qualities of an excellent anes- headings (MeSH) terms: general anesthesia, regional anesthesia,
thetic technique should include the following features: rapid spinal anesthesia, epidural anesthesia, lumbar spine, spine surgery,
onset, ease of reversal of effects, maintenance of hemodynamic discectomy, microdiscectomy, and laminectomy. We eliminated all
stability during operations without the need of blood trans- non-clinical articles, as well as those articles that did not feature
fusions, a decreased recovery room stay, as well as reduced simple, 1–3 level laminectomy, discectomy, or microdiscectomy as
post-op pain, nausea, vomiting, or additional anesthetic require- the surgical procedure, those that included hardware placement, or
ments. those that featured more complex surgical procedures. We chose
For lower trunk and limb surgical procedures, the litera- to focus on those surgical procedures most commonly performed,
ture notes various advantages of RA over GA, including reduced namely lumbar discectomy, laminectomy, or microdiscectomy.
pulmonary complications [2], intraoperative blood loss [3], peri- The following outcome variables, compared between RA and
operative cardiac ischemic incidents, hypoxic episodes, arterial GA groups across studies, were collected to constitute our anal-
and venous thrombosis [4], and decreased incidence of post- ysis: mean heart rate (HR), mean arterial pressure (MAP), blood
operative cognitive dysfunction, all of which suggests advantages loss, duration of surgery, post-operative (post-op) anesthesia care
of RA over GA in certain orthopedic procedures. Most recently, a unit (PACU) time, post-op narcotic use/pain scale, post-op urinary
French prospective cohort study reported that elderly patients who retention, and post-op nausea/anti-emetic use/vomiting. We chose
received GA in the past decade were significantly more likely to to exclude the frequently featured outcome variables “surgeon sat-
develop dementia than age-matched controls (relative risk 1.35, isfaction” and “patient satisfaction” because of lack of objectivity.
95% CI, 1.11–1.63), suggesting another advantage of using RA over
GA [5]. 3. Results
These findings highlight the need to explore the advantages and
disadvantages of RA techniques for common spine procedures such 3.1. Literature review
as laminectomy and discectomy. Proposed advantages of RA over
GA for spine surgery include the ability to carry out prolonged Our search yielded a total of 31 articles. We excluded studies
operations in the prone position without airway compromise [6,7], if they did not feature any of our designated outcome variables,
while also avoiding brachial plexus injury and pressure necrosis of had confounding factors in their experimental design, showed clear
the face because of patient self-positioning. RA also has the poten- demographic discrepancies between groups, or had missing statis-
tial to reduce length of inpatient stays and reduce overall hospital tical data. One study containing results relevant to our analysis was
costs. excluded because it did not report adequate statistical data [12].
Although spinal anesthesia is widely accepted for lower extrem- After applying the exclusory criteria, 12 studies remained. Two
ity surgeries and total join arthroplasties, GA is by far the most of the studies were noted to feature the same data and, as such,
frequently used anesthetic technique for common spinal surgi- were counted as a single study [10,11]. This yielded a final N of 11. Of
cal procedures such as microdiscectomy or lumbar laminectomy. these studies, spinal anesthesia was used as the RA technique in 8 of
This may be due to greater acceptance by patients, the ability to 11 studies and epidural anesthesia was used in 3 of 11 studies. The
easily extend the duration of an operation using GA, and/or anes- method of GA did not vary significantly between studies. Table 1
thesiologist preference for GA because of a more secure airway demonstrates an overview of study types. Table 2 demonstrates
establishment prior to patient placement in the prone position individual study characteristics.
[8].
Nevertheless, some centers have been using regional anes-
3.2. Hemodynamic status (heart rate, mean arterial pressure, and
thesia in lumbar spine surgery. For example, the authors
blood loss; Table 3)
of a Cleveland Clinic study state that spinal anesthesia has
been routinely used at their institution for over two decades
The hemodynamic status of patients was reported in all of the
and for patients of all ages undergoing lumbar spine pro-
11 reviewed studies in the form of one or more of the following
cedures [9–11]. Our neurosurgery group at the University of
Pennsylvania, Pennsylvania Hospital, has also routinely used
regional anesthesia for lumbar laminectomies and discec- Table 1
tomies. Overview of study types. Featured study types include randomized control trials
(RCT), case–control, prospective cohort, and retrospective studies.
Although several studies have been performed comparing out-
comes of RA versus GA for lumbar spine surgery, there have not Type of study Number of studies reviewed (N = 11)
been recent reports summarizing results across studies. Our goal is Randomized control trial (RCT) 4
to review the relevant literature to identify and compare intra and Case control trial 3
post-operative outcomes between regional and general anesthetic Prospective cohort 2
Retrospective cohort 2
approaches.
 J.O. De Rojas et al. / Clinical Neurology and Neurosurgery 119 (2014) 39–43
Table 2
Study characteristics, including study type, surgery performed, group sizes (N given for GA and RA groups), type of RA used (spinal or epidural).
Study Type
Attari et al., 2011 RCT
Demirel et al., 2003 RCT
Greenbarg et al., 1988 Case–control
Jellish et al., 1996 RCT
McLain et al., 2004; McLain et al., 2005 Case–control
Sadrolsadat et al., 2009 RCT
Tetzlaff et al., 1998 Retrospective
Rung et al., 1997 Retrospective
Chen et al., 2011 Prospective
Papadopoulos et al., 2006 Prospective
McLain et al., 2007 Case–control
variables: blood loss, heart rate (HR), mean arterial pressure (MAP).
Seven studies included blood loss data [1,8,13–17]. Of these, 4/7
studies reported no difference in blood loss between RA and GA
groups or they reported differences that did not reach statisti-
cal significance [8,14,16,17], and 3/7 studies reported a favorable
decrease in blood loss for the RA compared to GA group [1,13,15].
All 7/7 studies that featured HR and MAP variables, including
4 RCTs, reported a favorable hemodynamic outcome for the RA
over GA group in the form of lower mean HR, lower MAP, or a
smaller change in these outcomes across operative and immediate
post-op time [1,8–11,13,15,17]. In one study, these results were
deduced from decreased incidence of intraoperative tachycardia
and postoperative hypertension in the RA compared to GA group
[8]. Interestingly, one study did not report statistical testing data for
these hemodynamic outcomes, but it was included in the analysis
because it claimed statistical significance [9].
3.3. Surgery time (Table 3)
Anesthetic technique can affect the surgical procedure time,
or surgery time, which is a subdivision of total anesthesia time.
Nine total studies reported surgical time data, with 3 studies repor-
ting statistically decreased times for the RA compared to GA group
[10,11,13,15] and 6 studies showing no difference between groups
[1,8,14,16,18,19].
3.4. PACU time (Table 3)
As with total surgery time, the reviewed studies varied with
respect to PACU stay time between groups. A total of 7 studies
reported PACU time data. Two-of-seven studies reported longer
PACU times in the RA compared to GA group [9–11], 4/7 studies
reported no difference between groups [1,8,15,16], and 1 study
reported longer PACU stays for the GA compared to RA group [13].
Duration of hospital stay, although not chosen as an a priori out-
come variable, deserves mention since it is related to PACU time
and was reported in some studies. Two studies describe briefer
hospital stays for the RA compared to GA group [10,11,18], and
4 studies showed no significant difference in hospital stay time
between groups [1,14,16,19].
3.5. Post-operative narcotic use and/or pain score (Table 3)
The amount of post-op narcotic use, or the related variable “pain
score”, whether in the PACU or when the patient first arrives on
the floor, is reported in 9 of the studies. Seven-of-nine studies
reported favorable post-op pain outcomes for the RA relative to
GA group, with 4 of these studies reporting decreased incidence of
narcotic use [1,8,15,16], one study reporting lower analgesic dose
requirements [14], another study reporting lower morphine sul-
fate infusion rates [10,11], and another study reporting significantly
lower pain scores for the RA group [13]. Two-out-of-nine studies
41
Surgery N (GA, RA) RA used
Discectomy or laminectomy for amniotomy or spinal cord tumor 37, 35 Spinal
Lumbar partial hemilaminectomy and discectomy 30, 30 Epidural
Lumbar laminectomy or discectomy 40, 40 Epidural
Single- or double-level laminectomy or disc surgery 61, 61 Spinal
Laminectomy or laminotomy for spinal stenosis or herniated disc 200, 200 Spinal
Laminectomy for herniated lumbar disc 50, 50 Epidural
Discectomy or laminotomy for spinal stenosis 192, 611 Spinal
Lumbar disc surgery 7, 7 Spinal
Endoscopic interlaminar discectomy of L5-S1 50, 73 Spinal
Lumbar microdiscectomy 16, 27 Epidural
Microdiscectomy for herniated lumbar disc 33, 43 Spinal
reported statistically similar pain scores [19] or analgesic infusion
rates [9] between groups.
3.6. Post-operative urinary retention (Table 3)
Anesthesia choice can affect the severity of post-op urinary
retention, a variable featured in five of the featured studies. Three-
of-five studies reported post-op urinary retention rates to be more
common in patients undergoing GA [9–11,14]. Two-of-five studies
described no such difference between groups [13,15].
3.7. Post-operative nausea (Table 3)
Post-operative nausea was the final factor that we compared
between groups, and 8 of studies featured this data. Five-of-eight of
the studies showed a higher incidence of nausea [10,11,13,15,19] or
a higher incidence of anti-emetic use [16] in the GA compared to RA
group, but 3/8 studies reported no significant difference in post-op
nausea [1,8] or anti-emetic requirement [9] between groups.
4. Discussion
RA and GA are both reasonable anesthetic approaches for lum-
bar spine surgery as there is no clearly superior technique in terms
of morbidity or mortality [18]. However, many of the studies fea-
tured in this review suggest short-term, secondary benefits of RA
over GA. McLain’s randomized and controlled case–control study
of 400 patients [10,11] concluded that RA was at least as effec-
tive as GA for performing elective lumbar decompression surgeries
and proposed some advantages of RA over GA, including improved
patient perioperative hemodynamic profiles, decreased analgesic
requirement, and decreased incidence of post-op nausea. Of the 4
randomized controlled trials (RCTs) analyzed, 3 of them reported
similarly favorable hemodynamic status, blood loss, and post-op
analgesic requirement outcomes for their RA groups [1,13,15]. The
fourth RCT, Sadrolsadat et al.’s study [8], did not demonstrate as
clear an advantage between groups with regard to these param-
eters, although the authors did report a decreased incidence of
perioperative tachycardia, hypertension, and analgesic use in the
RA compared to GA group. Of note, the authors mention that their
use of propofol as a sedative in the RA but not GA group may
have confounded these outcomes [8], but this confounder was not
present in the other studies mentioned and is, as a result, is insuf-
ficient in explaining the favorable outcomes of RA.
In summary, all studies that featured heart rate and blood pres-
sure data (7/7) report favorable hemodynamic outcomes for the
RA over GA group, including 4/4 RCTs. More than half of the studies
that featured pain control outcome data (7/9), including 4/4 RCTs,
report favorable outcomes for RA. Additionally, more than half of
the studies that featured nausea/vomiting data (5/8), including 3/4
RCTs, suggested favorable outcomes for RA. For all other variables
 42
Table 3
Comparison of regional anesthesia to general anesthesia for lumbar spine surgery. Outcome variables include mean heart rate (HR) or maximum change in HR (max HR), mean arterial pressure (MAP) or maximum change in
MAP (MAP), intraoperative blood loss (in mL), surgery time (in min), PACU time (in min), post-op analgesic use (in % incidence or doses administered) or pain score (as reported in primary study), post-op urinary retention (in
% incidence), and post-op nausea (in % incidence or anti-emetic administration incidence). Outcomes variables, SDs (±value), SEMs (value) and P values are written as reported in primary studies.

Study HR or max HR MAP or max Blood loss Surgery time PACU time Analgesic use or pain Urinary retention Nausea
MAP score

Attari et al., 2011 GA: +17.5 ± 5.5 GA: +21.0 ± 6.7 GA: 350 ± 35 GA: 111.0 ± 7.4 GA: 50 ± 5.9 GA: 16.2% – GA: 2.7%
RA: −13.2 ± 3.9 RA: −25.1 ± 4.2 RA: 210 ± 40 RA: 115.0 ± 3.2 RA: 55 ± 6.7 RA: 0% SA: 5.7%
P < 0.05 (HR) P < 0.05 (MAP) P < 0.05 P > 0.05 P > 0.05 P < 0.05 (incidence) P > 0.05

Demirel et al., 2003 GA > RA across GA > RA across GA: 288.6 ± 112.5 GA: 137.6 ± 26.8 GA: 52.9 ± 10.2 GA: 3.5 ± 1.22 GA: 17% GA: 53%
time time RA: 180.4 ± 70.4 RA: 118.8 ± 35.4 RA: 34.4 ± 12 RA: 0.2 ± 0.5 RA: 20% RA: 10%
P < 0.05 P < 0.05 P < 0.05 P < 0.05 P < 0.05 P < 0.05 (pain score) P > 0.05 P < 0.05

Greenbarg et al., – – GA: 290 GA: 120.3 – GA: 3.2 GA: 50% –
1988 RA: 188.3 RA: 115.2 RA: 1.1 RA: 10%
P > 0.05 P > 0.10 P < 0.01 (doses) P < 0.001

J.O. De Rojas et al. / Clinical Neurology and Neurosurgery 119 (2014) 39–43
Jellish et al., 1996 GA > RA at PACU GA > RA across GA: 221 (32) GA: 81.5 (3.6) GA: 80.3 (2.8) GA: 80.3% GA: 22.9% GA: 25%
admission time RA: 133 (13) RA: 67.1 (2.8) RA: 85.4 (4.2) RA: 26.2% RA: 14.8% RA: 5%
P < 0.05 P < 0.05 P < 0.05 P < 0.05 P > 0.05 P < 0.05 (incidence) P > 0.05 P < 0.05

McLain et al., 2004; GA: 79 GA: 105 – GA: 120 GA: 120 GA: 1.0 GA: 24% GA > RA
McLain et al., RA: 72 RA: 95 RA: 105 RA: 225 RA: 0.6 RA: 8% P < 0.005
2005 P < 0.001 P < 0.001 P < 0.05 P < 0.001 P < 0.01 (doses/h) P < 0.001

Sadrolsadat et al., GA: 26% GA: 38% GA: 438 ± 67 GA: 94.1 ± 17.9 GA: 23.8 ± 7.8 GA: 62% – GA: 18%
2009 RA: 6% RA: 6% RA: 465 ± 69 RA: 94.4 ± 17.3 RA: 21.7 ± 8.8 RA: 22% RA: 10%
P < 0.01 P < 0.001 P > 0.05 P > 0.05 P > 0.05 P < 0.001 (incidence) P > 0.05
(tachycardia (hypertension
incidence) incidence)

Tetzlaff et al., 1998 GA: +21.2 (11.6) GA: +18.9 (5.6) GA = RA – – – – –

RA: −26.1 (4.0) RA: −14.2 (4.0) P > 0.05
P < 0.05 (HR) P < 0.05 (MAP)

Rung et al., 1997 – – GA: 63 ± 52 GA: 99 ± 57 GA: 87 ± 29 GA: 71% – GA: 57%
RA: 45 ± 33 RA: 96 ± 28 RA: 48 ± 38 RA: 0% RA: 0%
P > 0.1 P > 0.1 P > 0.1 P < 0.05 (incidence) P < 0.05
(incidence of
anti-emetic use)

Chen et al., 2011 – – – GA: 74.8 ± 17.7 – – – –

RA: 67.1 ± 33.9
P > 0.1

Papadopoulos – – – GA: 63.6 (26.6) – GA: 4 – GA: 71%

et al., 2006 RA: 65.4 (15.2) RA: 4 RA: 20%
P > 0.5 P > 0.5 (pain score) P < 0.05

McLain et al., 2007 GA > RA GA > RA – – GA: 144 GA: 2.0 GA: 21.2% GA: 6.1%
MSD MSD RA: 234 RA: 1.1 RA: 4.7% RA: 2.3%
P < 0.001 P > 0.5 (dose/h) P < 0.05 P > 0.5 (incidence
of anti-emetic
use)

Summary 7/7 7/7 3/7 3/9 1/7 7/9 3/5 5/8

GA > RA GA > RA GA > RA GA > RA GA > RA GA > RA GA > RA GA > RA
4/7 6/9 4/7 2/9 2/5 3/8
GA = RA GA = RA GA = RA GA = RA GA = RA GA = RA
2/7
RA > GA

–, results not recorded or reported; MSD, missing statistical data and P values; RA, regional anesthesia; GA, general anesthesia.
 J.O. De Rojas et al. / Clinical Neurology and Neurosurgery 119 (2014) 39–43
across studies, we believe that there were no clear advantages of
one approach over another.
4.1. Proposed mechanisms for favorable outcomes of RA
Improved hemodynamic stability of RA over GA, as suggested
by our review, is a possible result of inhibited release of stress
hormones intraoperatively, leading to less elevations and fluctua-
tions of MAP and HR [1,20–26]. Similarly, some researchers believe
that RA leads to decreased blood loss because of vasodilation and
hypotension caused by RA’s sympathetic blockade, as well as by the
maintenance of spontaneous ventilation possible with RA, which
leads to lower intrathoracic pressure and, as a result, less distension
of epidural veins [27]. Reduced bleeding in patients receiving RA,
although only reported in 3/7 studies, could be due to decreased
episodes of intraoperative hypertension as compared to the GA
groups [15].
More than half of studies demonstrated decreased post-op pain
scores and/or narcotic requirement for the RA compared to GA
group. The authors of one study highlights the existence of a resid-
ual sensory blockade after RA that is supported by the observation
that sensory recovery lags behind motor recovery in this group but
not in the GA group [1]. Finally, decreased pain scores in the RA
group may be due to regional anesthesia’s more selective inhibition
of afferent nociceptive sensitization pathways [1,28].
A little over half of studies also demonstrated decreased nausea
and anti-emetic use in the RA compared to GA group. To explain
this difference, it has been speculated that GA may inhibit gastric
emptying leading to increased nausea and vomiting, while this phe-
nomenon may be virtually absent with spinal or epidural anesthesia
use [9,23]. The increased incidence of nausea and vomiting could
also be due to N2 O gas use which was combined in the GA approach
in some studies [29].
4.2. When to not use RA
Despite the suggested advantages of RA over GA for simple,
1–2 level lumbar spine decompression surgeries, there are several
absolute and relative contraindications to RA, many of which were
used as patient exclusory criteria in the featured studies. These
include but are not limited to: patient refusal, severe or multilevel
spinal stenosis, history of seizures, history of intracranial hyperten-
sion, coagulopathy, infection at site of needle, hypovolemia, near
complete-total myelographic block, or myelographic demonstra-
tion of arachnoiditis [1]. It is also important to note that anesthetic
choice should ultimately be based on the patient’s, surgeon’s and
anesthesiologist’s comfort with the technique.
5. Conclusion
Both general and regional anesthesia are effective techniques
for use in 1–2 level lumbar laminectomy or disc surgery. There
is no evidence to suggest that morbidity, mortality, or long-term
complication rates differ between these two approaches [18]. How-
ever, our analysis of secondary outcomes across studies suggests
that RA can be a worthwhile, if not advantageous alternative to
GA in healthy patients undergoing simple lumbar decompressive
surgeries provided that no contraindications to RA exist. Because of
its suggested favorable hemodynamic profile and decreased post-
op narcotic requirement, we believe that the RA approach should
be considered in older patients who may not tolerate GA because
of a decreased cardiopulmonary reserve. In addition, older adults
may also benefit from RA by avoiding the increased risk of post-
operative cognitive dysfunction and theoretical risk of dementia
after GA exposure [5]. Future well-designed studies with more
43
sample cases will be needed to validate our results and shed light
on some of the proposed theoretical claims.
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