Abstract
Quasi-experimental design purpose
Compare intra and postoperative parameters, surgeons’ satisfaction, and cost-effectiveness between general anesthesia (GA) and spinal anesthesia (SA) on patients undergoing surgery in the lumbar spine surgery.
Overview of literature
Surgery on the lumbar spine is the commonest surgical procedure among all spinal surgical practices. Both the GA and SA are shown to be suitable techniques for performing the surgery safely. GA is used most frequently. But, SA became increasingly more popular because it allows the patient to self-position thereby reducing various complications associated with GA in a prone position.
Methods
A total of 64 patients from June 2016 to July 2019 who underwent either discectomy, laminectomy, or lamino-foraminotomy for herniated lumbar disc or canal stenosis in 1 or 2 levels were included. During the study period, 32 patients were non-randomly selected for each of the GA and SA groups. The heart rate (HR), mean arterial pressure (MAP), blood loss, total anesthetic time, surgeons’ satisfaction, analgesic requirements, cost of the procedure, and hospital stay were recorded and compared.
Results
In the context of demographic characteristics, baseline HR, or MAP, no significant differences were noted between SA and GA groups. Mean anesthetic time, mean PACU time, mean doses of analgesic requirement, cost of anesthesia, and the surgeon’s satisfaction was significantly lower in the SA Group (P < 0.05). The blood loss, duration of operation, and hospital stay were not significant too. No major Intra and postoperative complications were reported nor were significant differences found in either series.
Conclusion
Safety and efficacy of SA in comparison to GA were similar for the patients undergoing surgery on the lumbar spine. Notable advantages of SA include shorter anesthesia duration, fewer drug requirements, relative cost-effectiveness, and fewer complications rate. Successful surgery can be performed using either anesthesia type.
Keywords: Lumbar spine surgery, Spinal anesthesia, General anesthesia
1. Introduction
Surgery on the lumbar Spine is the commonest surgical procedure that is encountered among all spinal surgical practices.1 These include discectomy, laminectomy, or lamino-foraminotomy. Results are almost similar regardless of operative techniques (macro versus micro) and types of anesthesia used.2,3 All these procedures can be safely performed either by using general anesthesia (GA) or regional anesthesia i.e. spinal anesthesia (SA). GA has traditionally been preferred by anesthesiologists as well as surgeons because it is widely accepted by patients and facilitates surgery of long duration with patients in a prone position in a secured airway.4 In contrast, SA may also be used for these procedures and recent research has supported its use as an alternative.5,6
Several studies compared peri & postoperative complications, hemodynamic parameters, cost-effectiveness and operative, anesthesia, and recovery times between GA and SA in spinal procedures.7, 8, 9, 10, 11, 12, 13 Most of these studies observed fewer complications, more favorable hemodynamic parameters, and shorter anesthetic time spent with SA than with GA suggesting that this anesthetic modality may even be a superior alternative to the perceived standard of care.14, 15, 16, 17, 18, 19 But some studies found no difference in peri & post-operative outcomes between SA and GA. Even GA seems to be superior in some respects particularly in surgeon satisfaction.20,21 This clearly emphasized the necessity of further study that must be performed before the conclusion elucidated.
Moreover, recent data showed that lumbar spine surgery has been increasing day by day and constitutes a sizable portion of health care spending throughout the world.22 Therefore, in the context of perioperative outcomes and the relative cost of these procedures, providers, and administrators may seek to provide more cost-effective care. In our country cost-effectiveness has a definitive role in decision making. Nonetheless, several studies reported that SA is a more cost-effective alternative to GA.10,11,23 The presence of conflicting evidence in the literatures, we decided to evaluate the role of GA vs SA in our group of patients and as relevant to out clinical practice. So the present study is aimed at comparing the intra and postoperative outcomes, cost-effectiveness after SA or GA techniques, when employed in patients undergoing lumbar spine surgery.
2. Material and methods
2.1. Ethics and inclusion criteria
This cross-sectional analytical study was done at a tertiary level hospital after approval of the study protocol by the institutional ethical board committee. A total of sixty-four (64) patients with American society of anesthesiologist (ASA) physical status (I, II) aged 21–75 years old from June 2016 to July 2019 were selected for the study. Surgical procedures include either discectomy, laminectomy, or lamino-foraminotomy for lumbar disc prolapse or lumbar canal stenosis in 1 or 2 levels. The power value was evaluated using the G-power v.3.1 package program. An A priori power analysis based on a previously published study20 which included At least 30 patients per group that were needed to achieve 80% power and detected a 20% difference among the groups in the context of anesthesia time with α equal to 0.05.
Exclusion criteria were patients with ASA class higher than class II or having multilevel spinal stenosis, coagulopathy, localized infection (interpreted as a contraindication or a high risk for SA), or severe cardiac or liver disease; and cases with any relative or absolute contraindication for SA.8
Informed written consent was taken from all the patients mentioning the details of the procedure as well as modalities of treatment. Then, the patients were divided into two groups by placing odd numbers to the GA group and even numbers to the SA group in a consecutive group of patients of LCS and PIVD. Each group comprises 32 patients. All surgeries are carried out by the same surgeon and anesthetist. An expert technologist was responsible for gathering the required information who is unaware of the objectives and surgical procedures of this study.
2.2. Techniques
Premedication was not given to any of the patients. Patients were anesthetized with Propofol (2 mg/kg IV), and Fentanyl (1.5 μg/kg IV) in the GA group. Atracurium (0.6 mg/kg IV) was given to facilitate the endotracheal intubation. Maintenance of anesthesia was done by 1.2% isoflurane and nitrous oxide 50% in oxygen. For intraoperative analgesia, pethidine (80 mg) was chosen. The patients were positioned into prone, arms resting on the side of the head with the elbow flexed at 90°. The faces were placed on a headrest made of sheets to reduce the pressure on the nose and the eyes.
During the surgery, all vital parameters i.e. HR, SBP, DBP, and MABP, and oxygen saturation were monitored every 15 min interval. At the end of the operation, the anesthetic drugs were discontinued while patients received 100% oxygen. Subsequently, neuromuscular blockade reversal was withdrawn by administering neostigmine and atropine. Spontaneous respiration, pulse oximeter oxygen saturation >95%, end-tidal CO2 35–40 mmHg, respiratory rate <30/minutes, and tidal volume >5 ml/kg was ensured before extubation and transferred to the post-anesthetic care unit (PACU).
During surgery, if there was bradycardia (heart rate <50/minute) or hypotension (SBP< 90 mmHg), 0.5 mg atropine or 5 mg ephedrine was administered. To maintain hypotensive anesthesia for better visualization of surgical field, propofol infusion of 25–50 μg/kg/min IV was given which also had a sedative action. Propofol was stopped and the position was changed from prone to supine after surgery. Patients were transferred to the PACU and then shifted toward after withdrawal of neuromuscular blockade and control of pain and nausea.
In the SA group, the patients were preloaded with 7 ml/kg Lactated Ringer’s solution over 10–15 min. Before giving spinal anesthesia, we routinely counseled the patient about the procedure. Sometimes we need to use anxiolytics to calm the patient to avoid movements during the procedure. The patient is placed on a firm surface; the lumbar laminae and spines are ‘separated’ maximally by flexing the whole spine (including the neck), the hips, and knees; rotation and lateral curvature of the spine are avoided. One assistant was needed to achieve and maintain the correct position. Painting and draping were done later. Thereafter, spinal anesthesia was performed using a 25-gauge spinal needle at either the L2-3 or L3-4 interspace depending on the location of pathology. The exact level of pathology was double-checked in MRI sagittal long film as well as in fluoroscopy. No spinal anesthesia was performed in the level of pathology. Two patients required two attempts to complete the procedure. CSF leakage after giving spinal anesthesia was not observed in any case. After observing spinal fluid, 3.0–3.2 ml 0.5% bupivacaine in an 8.5% dextrose solution combined with fentanyl was administered into intrathecal space, and patients were placed in supine. To prevent displacement at any stage, the dorsum of one hand was anchored firmly against the patient’s back and the fingers used to immobilize the needle, while the other hand is used to manipulate the syringe. After the establishment of the spinal anesthesia and waiting 5–10 min, the patients were placed in a prone position. Oxygen was given at a rate of 2L/minutes via the nasal cannula. SA was given in the operation theatre, not in a separate room.
3. Data collection
Before surgery, age, gender, BMI, and ASA status were recorded. HR and MABP were recorded after initiation of anesthesia, after initiation of surgery, after completion of the surgery, and finally after completion of anesthesia. HR and MABP were also recorded on admission to the PACU and before shifting to the general ward. Blood in suction bottles and the weight of bloody gauze were the tools to measure intra-operative blood loss. All fluids added to the surgical field were quantified and deducted from the measured volume of blood in suction bottles.
The satisfaction of the surgeon was assessed considering the subjective opinion of the surgeon about the anesthesia in the context of bleeding, movement of the patient, muscle relaxation, and surgical field of vision, and scoring was done in a 100-point visual analog scale (VAS). Duration of anesthesia (time from the patient’s entry into the operating room until transfer to the PACU), duration of surgery (time from incision to placement of surgical dressing), and duration in the PACU (total time in the PACU until shifted to the ward/cabin) were recorded for each patient. Hemodynamic changes, including tachycardia, bradycardia, hypertension, and hypotension, were recorded during surgery and PACU stay. A decrease of 25% or an increase of 25% from baseline in MABP was termed as hypotension and hypertension, respectively. HR values > 100 bpm and <50 bpm was defined as tachycardia and bradycardia, respectively. At PACU, PONV incidence was noted and the requirement of analgesia after surgery was recorded. A 100-point VAS was used to evaluate the severity of pain and nausea. If the VAS for pain or nausea score is severe, Meperidine 25 mg IV, and metoclopramide 10 mg IV were administered. If necessary, Meperidine was given every 30 min interval. The cost of anesthesia for each patient, including supplies (spinal needle, local anesthetic, ventilation tubes and bag, filter, syringes, fluids, and oxygen masks), drugs, and gases were recorded from the start of anesthesia to discharge from the PACU. The data obtained from the hospital information management system database were used to calculate the cost in USD. On calculating the cost in the SA, we included the drugs, fluids, fluoroscopy, operation theatre charge, and anesthetist charge. Drugs used in operation theatre include antibiotics, analgesics, antiulcerant, antiemetic, tranexamic acid, and sedative. Equipment used like surgical gauge, povidone-iodine, hexisol, foley’s catheter, urobag, Iv cannula, syringes, and threeway stopcock. Some of them were used on the requirement. In the case of the GA group, GA drugs and gas were included in the calculation and spinal drugs were excluded. The PACU, monitors, and anesthetic machines associated cost were not within the calculated anesthesia costs.
4. Statistical analysis
SPSS v.25.0 (SPSS. Chicago. the USA) was used for statistical analysis. The variable distribution was determined by The Kolmogorov–Smirnov test. The independent sample t-test and the chi-square test were used to compare the data. Nonparametric statistical methods were used to analyze heterogeneous variables. Mann–Whitney U test was used to analyze nonparametric variables. The level of statistical significance was set at P < 0.05.
5. Results
The demographic characteristics, baseline HR, or baseline MABP between the two groups were not statistically significant (Table 1). Surgery was successfully done in all cases and no spinal anesthesia had to be converted into general anesthesia.
Table 1.
Patient characteristics.
| Variable | Group SA | Group GA | P-value |
|---|---|---|---|
| Age (years) | 50.53 ± 10.881 | 47.38 ± 9.87 | .229 |
| Gender (M/F) | 21(65.6%)/11)(34.4%) | 18(56.3%)/14(43.8%) | .442 |
| ASA(I/II) | 12(37.5%)/20(62.5%) | (15(46.9%)/17(53.1%) | .448 |
| Baseline HR | 77.94 ± 5.80 | 78.19 ± 6.2 | .878 |
| Baseline MAP | 90.88 ± 4.24 | 91.59 ± 3.71 | .473 |
| Diagnosis- | DH: 20(62.5%) | DH: 25(78.10%) | .171 |
| LCS: 12(37.5%) | LCS: 07(21.9%) | ||
| No. of the level involved | One: 26(81.3%) Two: 6(18.8%) |
One: 26(81.3%) Two: 6(18.8%) |
1.000 |
| Most common level | L4/5 (40.6%) | L5 S1(34.45%) | 0.486 |
Values are expressed as number ratio or mean + SD, DH: Disc herniation, LCS: Lumbar canal stenosis, M/F: Male/female.
Perioperative findings are shown in Table 2.
Table 2.
Surgery/anesthesia-related intraoperative parameters.
| Variable | Group SA | Group GA | P-value |
|---|---|---|---|
| Anesthetic time | 103.44 ± 15.79 | 119.59 ± 16.53 | .000 |
| Surgical time(min) | 84.19 ± 9.93 | 82.16 ± 15.41 | .533 |
| Blood loss (ml) | 87.47 ± 19.22 | 83.72 ± 18.50 | .430 |
| Intraoperative tachycardia(n) | 7(21.87%) | 7(21.87%) | 1.000 |
| Intraoperative bradycardia(n) | 4(12.5%)± | 1(3.13%) | .162 |
| Intraoperative hypertension(n) | 7(21.86%) | 4(12.5%) | .320 |
| Intraoperative hypotension(n) | 6(18.75%) | 4(12.5%) | .491 |
| Surgeons satisfaction(100 point VAS) | 65.25 ± 4.45 | 77.38 ± 4.59 | .000 |
Values are expressed as mean ± SD, numbers (n), and percentages (%).
GA: general anesthesia, SA: spinal anesthesia, VAS: visual analog scale. ∗P < 0.05.
Though the duration of surgery did not differ significantly between the two groups (P = 0.533) but anesthetic time was significantly shorter in the SA group than in the GA group (103.44 ± 15.79 min vs.119.59 ± 16.53 min, P < 0.05). The SA group has relatively more blood loss (4 ml) in comparison to the GA group (87.47 ± 19.22 ml vs.83.72 ± 18.50, P = 0.430) but statistically insignificant. Surgeon satisfaction was significantly lower in the SA group (VAS satisfaction score: 65.25 ± 4.45 vs. 77.38 ± 4.59, P < 0.05). The incidence of hemodynamic changes, including hypotension, hypertension, bradycardia, and tachycardia, were similar in both groups during the perioperative period (Table 2, Table 3). Intraoperative maximum mean arterial blood pressure and heart rate changes were significantly less in SA compared with GA(P < 0.05).
Table 3.
Postoperative parameters.
| Variable | Group SA | Group GA | P-value |
|---|---|---|---|
| PACU time (min) | 36.13 ± 9.66 | 130.84 ± 43.95 | .000 |
| Tachycardia(n) | 6(18.75%) | 8(25%) | .545 |
| Bradycardia(n) | 6(18.75%) | 8(25%) | .545 |
| Hypertension(n) | 7(21.875%) | 12(37.5%) | .171 |
| Hypotension(n) | 4(12.5%) | 7(21.875%) | .320 |
| Nausea/vomiting(n) | 5(15.63%) | 14(18.36%) | .014 |
| Analgesic dose require in the 1st 24 h | 2.31 ± .592 | 3.22 ± .491 | .000 |
| Hospital stay(days) | 2.66 ± .602 | 2.94 ± .564 | 0.058 |
| Cost of anesthesia (USD) | 164.03 ± 15.52 | 279.06 ± 11.75 | 0.000 |
Values are expressed as mean, SD, numbers (n), and percentages (%), GA: general anesthesia SA: spinal anesthesia, VAS: visual analog scale, PACU: post-anesthetic care unit, ∗P < 0.05.
Postsurgical findings are shown in Table 3.
The duration of PACU time was significantly less in the SA group, with a P-value of 0.000 and but the duration of hospitalization was 2.66 ±.602 and 2.94 ± 0.564 days for the SA and GA respectively (P = 0.058) which was insignificant. The percentage of patients with POVN was less in SA groups (15.63%)of the SA vs. 18.36% of the GA; P = 0.014). The analgesic requirement was significantly lower in the SA group than the GA group postoperatively (2.31 ± 0.592 versus 3.22 ± 0.491, P < 0.000). Anesthetic costs were significantly lower in the SA group than the GA group (164.03 ± 15.52 vs 279.06 ± 11.75, P < 0.001) (Table 4, Table 5).
Table 4.
Cost of anesthesia in the SA group.
| Variable | Mean (USD) | Std. Deviation (USD) |
|---|---|---|
| Spinal needle | 1.77 | 0.00 |
| Fentanyl | 0.47 | 0.00 |
| Lignocaine | 0.47 | 0.00 |
| Bupivacaine | 0.71 | 0.00 |
| Equipments used in OT | 34.29 | 0.99 |
| Drugs used in OT | 5.51 | 0.28 |
| OT_charge | 41.06 | 5.22 |
| Fluroscopy | 33.04 | 6.30 |
| Anesthetist | 44.01 | 2.66 |
| Total expenditure in USD | 164.03 | 15.52 |
Table 5.
Cost of anesthesia in GA group.
| Variable | Mean (USD) | Std. Deviation (USD) |
|---|---|---|
| GA drugs | 60.50 | 20.07 |
| Fluoroscopy | 53.60 | 9.61 |
| Operation theatre charge | 61.22 | 9.20 |
| Equipment used in Operation theatre | 34.29 | 0.99 |
| General drugs | 5.51 | 0.28 |
| Anesthetist charge | 63.94 | 6.53 |
| Total expenditure | 279.06 | 11.75 |
No major intra and post-operative complications were reported nor significant difference was found in either series.
6. Discussion
Lumbar spine surgery can be done either by using GA or SA; however, only a limited number of randomized, controlled prospective studies have been performed to determine which anesthetic technique has better compliance with fewer complications rate and lower anesthesia costs. McLain et al.8 reported SA was as effective and safe as GA in lumbar spine surgery. Shorter duration of anesthesia, lower PONV and analgesic requirement, and fewer side effects were also noted by them. Conversely, Sadrolsadat et al.21 concluded that GA has more advantages and it decreases the incidence of side effects related to anesthesia. They recommended that high quality randomized clinical trials were needed to validate their findings.
The present study showed that the anesthesia period was significantly brief in the SA group which was consistent with McLain et al.8 It is because more time is required to intubate, extubate, and transfer the patient to the post-operative room which is not needed in SA. Furthermore, less assistance is required for positioning the patients for SA.4,10,11 We think another advantage of SA and its associated shorter duration of anesthesia is that it facilitates more efficient use of the operating room. Moreover, the time spent in giving the SA was much lesser than the GA.
A statistically insignificant difference in blood loss was observed in both groups in our study as evident in Sadrolsadat et al.21 But Jellish et al.7 showed less intraoperative blood loss in an RCT consists of 122 patients undergoing lumbar disc surgeries.
Jellish et al.7 reported that patients in their SA group required longer PACU stays than those in their GA group. But, Sadrolsadat et al.21 did not note any difference in PACU stays between SA and GA groups. Our study showed that the GA group may have longer PACU stay. The duration of hospitalization was statistically insignificant between the two groups.
The analgesic requirement in the postoperative period was significantly less in the SA group than the GA group, which is evident in this study. Sadrolsadat et al.21 also reported more analgesic administration in the GA group. Jellish et al.7 reported that patients requested 4 times more analgesic postoperatively in GA than SA. There may be a pre-emptive effect in which SA reduces the pain response by inhibiting nociceptive pathways.18,23 In the present study, both HR and MABP were also more physiologically stable in SA patients during PACU admission. These findings may have resulted in lower stress and pain in patients undergoing lumbar disc surgery in the SA group. The same analgesics were used in both groups but more doses were required to control pain in the GA group.
A lower incidence of PONV in the SA patients was noted in this study. Because nausea is a known side effect of meperidine that is more frequently used as an analgesic in the GA group with a high consumption rate. Salman et al.24 supported our result that postoperative nausea was more prevalent in the intravenous meperidine group than in the epidural bupivacaine group.
No major intro and postoperative complications were reported nor significant difference is found in either series. It is known that urinary retention is a frequent complication after spinal anesthesia and this situation depends on bladder muscle relaxation. Patients who received intrathecal opioids usually develop urinary retention. However, Silver et al.25 reported more incidence of urinary retention in patients with general anesthesia. In our study, we routinely advise the patient to void the urinary bladder just before entering the operating room. After that, the spinal anesthesia was achieved with bupivacaine and none of the patients had urinary retention.
Despite adequate anesthesia and statistically insignificant duration of surgery between the two groups, the surgeon’s satisfaction was lower in the patients received SA. Surgeons are more familiar with GA and awake patients adversely affect their satisfaction in the SA group, which may also lead to prolonged duration of surgery. But, significantly better patient and surgeon satisfaction were observed by Dagher et al.12 in the SA group. Sadrolsadat et al.21 noted surgeon satisfaction similar to the present study. Due to the motor blockade in SA, patients’ neurologic status couldn’t be evaluated by the surgeons immediately after the surgery which is a major pitfall of SA for lumbar disc surgery. It is worthy to mention that surgeons’ satisfaction rate is evaluated in very few studies in this field. It is because, there is no standard scaling technique to measure it, and to develop a reliable VAS, cooperation between the anesthesiologist and the surgeon is mandatory.
Due to worldwide budgetary limitations, effective health services at the lowest possible cost are necessary. Schuster et al.26 showed that SA is more economical than GA in their retrospective study. Several studies also support this evidence26, 27, 28 which was also observed in this study. The most important reason for this result is that the cost of medications used in spinal anesthesia is much lower than in general anesthesia. The instruments, gas, and intravenous medications used in general anesthesia make it costlier than SA. Also, complications after general anesthesia tend to increase the cost. In our study, we found that 115 USD was saved in spinal anesthesia and if more patients get used to the idea of day surgery this will further decrease the total cost.
7. Conclusion
As long as patients are selected carefully, Spinal anesthesia is a reasonable alternative to general anesthesia for the patients with ASA grade I/II and preferably single level pathology in the lumbar spine. Potential advantages of spinal anesthesia include a shorter anesthesia duration, decreased nausea, lower antiemetic and analgesic requirements, fewer complications, and relative cost-effectiveness.
Author contribution
Dr Sharif Ahmed Jonayed: Conception, Drafting and design (see Table 5)
Prof. Dr Md Shah Alam: Revising the article.
Dr. Abdullah Al Mamun Choudhury: Analysis and interpretation of data.
Dr Sohely Akter: Acquisition of data.
Dr Shubhendu Chakraborty: Acquisition of data.
Source of funding
Self.
Declaration of competing interest
None.
Contributor Information
Sharif Ahmed Jonayed, Email: dr.jonayed@gmail.com.
Md Shah Alam, Email: dr.s.alam@hotmail.com.
Abdullah Al Mamun Choudhury, Email: mamuncomc@gmail.com.
Sohely Akter, Email: dr.sohelyakter@gmail.com.
Shubhendu Chakraborty, Email: shubhendumccy2k@gmail.com.
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