Abstract
Study design
Meta-analysis.
Objectives
Perform a systematic review and meta-analysis to determine the perioperative utility of general versus spinal anesthesia in the lumbar spine surgery population.
Methods
PubMed and Embase were queried for manuscripts reporting perioperative outcomes for patients undergoing one to three-level lumbar spine surgery (including decompression, fusion, and decompression with fusion) using either general or spinal anesthesia. Inclusion criteria included studies published from 2005 to 2021, in English, involving primary data from human subjects. Studies were further screened for data on total operative time, blood loss, intraoperative hypotension, pain scores, postoperative nausea and vomiting, time required in post-anesthesia care unit (PACU), PACU pain anesthetic requirement, and length of stay. Risk of bias for each study was assessed using standardized tools (i.e., RoB 2, ROBINS-I, NOS, as appropriate). Potential predictors of outcome were compared using univariate analysis, and variables potentially associated with outcome were subjected to meta-analysis using Cochran-Mantel-Haenszel testing to produce standard mean differences (SMD) or odds ratios (OR) and 95% confidence intervals (CI).
Results
In total, 12 studies totaling 2796 patients met inclusion criteria. 1414 (50.6%) and 1382 (49.4%) patients underwent lumbar spine surgery with general anesthesia and spinal anesthesia, respectively. Patients undergoing spinal anesthesia were statistically more likely to have coronary artery disease and respiratory dysfunction. Total operative time (SMD: 12.62 min, 95% CI -18.65 to −6.59), estimated blood loss (SMD: 0.57 mL, 95% CI -0.68 to −0.46), postoperative nausea and vomiting (OR = 0.20, 95% CI 0.15 to 0.26), time required in PACU (SMD = −0.20 min, 95% CI -0.32 to −0.08), and length of stay (SMD = −0.14 day, 95% CI -0.18 to −0.10), all statistically significantly favored spinal anesthesia over general anesthesia (p < 0.05).
Conclusion
In one to three-level lumbar spine surgery, current literature supports spinal anesthesia as a viable alternative to general anesthesia. As this was a heterogeneous patient population, prospective randomized trials are needed to corroborate findings.
Keywords: Spinal surgery, Spinal anesthesia, General anesthesia, Lumbar
1. Introduction
Lumbar spine surgery has traditionally been performed under general anesthesia (GA). Recently, there has been an increase in the use of spinal anesthesia (SA) as an alternative to GA. Both GA and SA have proven to be safe and effective in lumbar spine surgery. 1,2 However, when comparing perioperative and postoperative outcomes between the two forms of anesthesia, the current literature is limited and offers conflicting views.
For example, some studies report shorter surgical and anesthetic time perioperatively and decreased pain medication and nausea postoperatively with SA. 3 Meanwhile, others report no significant difference in these metrics. 4 A 2017 meta-analysis found no evidence of difference in operative time, blood loss, or postoperative nausea and vomiting or pain scores. 5 Given the inconsistency within the current literature, a definitive advantage of one anesthetic type over another during lumbar spine surgery has yet to be clearly identified.
Considering the lack of clarity with the current literature, the authors sought to perform a large meta-analysis aimed to provide a more comprehensive and current comparison of perioperative and postoperative outcomes with SA and GA in lumbar spine surgery.
2. Methods
This meta-analysis was prepared in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 6
2.1. Literature search
A systematic search was performed in the PubMed and Embase databases using the search strategy “(((Anesthesia, Spinal [MeSH]) OR (Anesthesia, General [MeSH]))) AND lumbar surgery.” The search was restricted to titles available in English published between 2005 and January 2021. Eligibility criteria for selected studies were as follows: 1) Patients who underwent lumbar spinal surgery with 2) spinal anesthesia compared to general anesthesia, with the following granular perioperative outcome measures 3) total operative time, 4) intraoperative hypotension, 5) estimated blood loss, 6) postoperative nausea and vomiting, 7) narcotic requirement, 8) pain scores, 9) time in the post-anesthesia care unit (PACU), and 10) length of stay. Only studies reporting primary data were included.
2.2. Data extraction
Two investigators independently screened reports from the initial search by title and abstract content (DU, BS). The full text was retrieved for publications which met the above inclusion criteria. Data review was performed independently by two authors. Any disagreements regarding inclusion or data extraction were solved by discussion or mediation with a third author (TYW). Demographic data (e.g. average age, gender distribution, BMI, etc.), and study characteristics (e.g. anesthesia protocols, randomization technique, type of procedure performed, etc.) were also collected when available.
2.3. Risk of bias assessment
Risk of bias was evaluated using the Cochrane RoB 2 tool for randomized controlled trials, the ROBINS-I (Risk of Bias in Non-randomized Studies of Interventions) tool for non-randomized prospective studies, and the Newcastle-Ottawa Scale (NOS) for comparative studies. 7, 8, 9 The RoB 2 tool assesses for five categories of bias in randomized trials: (1) randomization and allocation; (2) deviations; (3) incomplete outcome data; (4) measurement methodology; (5) selective reporting. Each category was rated as “low risk,” “some concerns,” or “high risk.” A study's overall risk of bias was rated as high if at least one category was rated as high risk. The Newcastle-Ottawa Scale assesses bias in comparative studies through review of cohort selection, cohort comparability, and outcome assessment. The ROBIN-I tool assesses bias in seven domains: (1) baseline confounding variables; (2) selection of participants; (3) classification of intervention; (4) deviation from intended intervention; (5) missing outcome data; (6) measurement of outcomes; (7) reported results. We also evaluated each outcome for publication bias using funnel plots.
2.4. Statistical analysis
Analysis of the collected data was performed with the Review Manager software version 5.4. For continuous outcomes, the intervention effect was calculated as a standardized mean difference (SMD) with 95% confidence intervals (CI). This helped account for multilevel surgery and the need for fusion which induce higher variability within the data series. For dichotomous outcomes, odds ratios (OR) were used. Heterogeneity was calculated using both Chi-squared and I2. Heterogeneity was assumed to be high when I2 exceeded 50%. Pooling was done using a fixed-effect model, though a random-effects model was used if heterogeneity was high. Statistical significance was assumed for p values less than 0.05. For a given outcome, each study reporting sufficient metrics (e.g., mean and standardized deviation) were included in the analysis. Conversely, studies which did not report all required metrics for a given outcome were excluded. Unit conversions were performed where necessary (e.g., days to hours). Analysis results were displayed in forest plots.
3. Results
3.1. Search and study selection
Search results are depicted in Fig. 1 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The initial search yielded 386 titles. After screening by title and abstract, 36 publications remained. One publication was excluded because the full text could not be obtained. 10 A further 23 titles were excluded on review of their full text. As shown in Fig. 1, reasons for full text exclusion included inadequate reported data (e.g., study did not report at least one of the outcomes of interest, study reported data in a non-standardized fashion, etc.) and incompatible study design (e.g., study was structured as case report, study included only information about one anesthesia type, etc.).
Fig. 1.
PRISMA flowsheet depicting study selection process.
3.2. Study characteristics
All 12 included studies reported primary data comparing spinal anesthesia to general anesthesia for spinal surgery. Of 2796 total patients, 1414 received spinal anesthesia (50.6%) and 1382 received general anesthesia (49.4%). The characteristics of included studies are shown in Table 1. Further demographic information is available in Table 2.
Table 1.
Study characteristics.
| Study | Groups (N) | Type | SA | GA | Procedure | # Levels |
|---|---|---|---|---|---|---|
| Sadrolsadat et al., 200911 | SA (50) | Randomized Controlled Trial | 4 mL of bupivacaine 0.5% | Induction: propofol IV (2 mg/kg) and fentanyl IV (2 μg/kg) Maintenance: oxygen 100% with propofol (100–200 μg/[kg min]) and alfentanil (2 mL/400 mg propofol) | Laminectomy | 1–2 |
| GA (50) | ||||||
| Nicassio et al., 201012 | SA (23) | Nonrandomized Prospective Study | 8–10 mL of ropivacaine 0.75% | NRa | Microdiscectomy | NR |
| GA (238) | ||||||
| Schroeder et al., 201113 | SA (19) | Retrospective Comparative Study | “100 μg of fentanyl and 15–20 mL of 0.5% ropivacaine, 0.5% bupivacaine, or 2% lidocaine" | Induction: “thiopental sodium or propofol and fentanyl” Maintenance: “an inhaled anesthetic" | ALIF | 1 |
| GA (83) | ||||||
| Kahveci et al., 201414 | SA (40) | Randomized Controlled Trial | 3 mL of bupivacaine 0.5% | Induction: fentanyl 2–4 mg/kg IV and propofol 3–5 mg/kg IV Maintenance: sevoflurane 1.5–2 vol% in 2.0 L of fresh gas flow (FiO2, 0.4) | Not Reported | 1 |
| GA (40) | ||||||
| Dagistan et al., 201515 | SA (90) | Retrospective Comparative Study | 3 mL 0.75% bupivacaine 8.5% dextrose solution | Induction: ropofol (2 mg/kg), fentanyl (5 mg/kg), and vecuronium 0.1 mg/kg Maintenance: N2O/O2 (2:1), isoflurane (0.3%) and fentanyl 1.2 mg/kg/hour | Microdiscectomy | 1–2 |
| GA (90) | ||||||
| Ulutas et al., 201516 | SA (573) | Retrospective Comparative Study | 14–16 cm3 mix of 50 lg fentanyl (1 cm3), 100 mg lidocaine hydrochloride (5 cm3) and 50 mg bupivacaine (10 cm3) | Induction: 1 lg/kg remifentanil, 2–3 mg/kg propofol and 0.5 mg/kg rocuronium Maintenance: 0.25 lg/kg remifentanil, 2–2.5% sevoflurane and 4 L/min fresh gas flow (50% O2/50% air mix) | Microdiscectomy | 1–2 |
| GA (277) | ||||||
| Agarwal et al., 201617 | SA (326) | Retrospective Comparative Study | “One or a combination of the following agents … procaine, lidocaine, tetracaine, bupivacaine, and levobupivacaine" | “one or a combination of the following agents: propofol, nitrous oxide, desflurane, halothane, isoflurane, and sevoflurane" | Discectomy/Laminectomy | SA 1.7 (1.3) |
| GA (148) | GA 2.4 (1.4) | |||||
| Mean (std. dev) | ||||||
| Finsterwald et al., 201818 | SA (146) | Retrospective Comparative Study | plain bupivacaine 0.5% (5–10 mg) | “induced and maintained using propofol and remifentanil TCI with additional fentanyl for analgesia" | Decompression | SA 1-4 |
| GA (292) | GA 1-2 | |||||
| Dashtbani et al., 201919 | SA (36) | Randomized Controlled Trial | NR | NR | Microdiscectomy | 1 |
| GA (36) | ||||||
| Kilic & Nediri, 201920 | SA (50) | Randomized Controlled Trial | 3 mL of 0.5% bupivacaine | Induction: propofol 2 mg/kg and fentanyl 1 μg/kg IV maintain: 2% sevoflurane in 50%: 50% air/oxygen | Microdiscectomy | 1 |
| GA (50) | ||||||
| Sekerak et al., 202021 | SA (29) | Retrospective Comparative Study | NR | NR | TLIF | 1–2 |
| GA (46) | ||||||
| Jonayed et al., 202122 | SA (32) | Nonrandomized Prospective Study | 3.0–3.2 mL 0.5% bupivacaine in an 8.5% dextrose solution combined with fentanyl | Induction: Propofol (2 mg/kg IV), and Fentanyl (1.5 mg/kg IV) Maintenance: 1.2% isoflurane and nitrous oxide 50% in oxygen | Discectomy or Laminectomy or Lamino-foraminotomy | 1–2 |
| GA (32) |
NR = Not Reported; # Levels is reported as a range unless otherwise indicated.
Table 2.
Demographic data.
| Demographic | Spinal Anesthesia (n = 1414) | General Anesthesia (n = 1382) | p |
|---|---|---|---|
| Age (years) (mean ± STD) | 51.6 ± 15.8 | 54.6 ± 15.6 | <0.001 |
| Gender | <0.001 | ||
| Female | 629 | 740 | |
| Male | 785 | 642 | |
| Body mass index (kg/m2) (mean ± STD) | 26.5 ± 4.4 | 27.5 ± 4.7 | 0.006 |
| Diabetes | 0.08 | ||
| Yes | 127 | 97 | |
| No | 385 | 383 | |
| NRa | 902 | 999 | |
| Hypertension | 0.06 | ||
| Yes | 236 | 193 | |
| No | 236 | 247 | |
| NR | 942 | 942 | |
| Coronary Artery Disease | <0.001 | ||
| Yes | 71 | 60 | |
| No | 75 | 232 | |
| NR | 1268 | 1090 | |
| Respiratory Disease | <0.001 | ||
| Yes | 51 | 36 | |
| No | 95 | 256 | |
| NR | 1268 | 1090 |
Not reported (NR) values were not used for significance testing.
3.3. Bias assessment
Four of four randomized control studies evaluated with the RoB 2 tool displayed some risk for bias. However, none were categorized as high risk. One non-randomized prospective trial evaluated with the ROBINS-I tool was rated as serious risk and another as moderate risk. All six retrospective studies were rated as low risk according to NOS. See Table 3, Table 4, Table 5 for bias assessment detail. Funnel plots for each outcome are available in supplemental data (Figs. S1–S6). These display some asymmetry indicating a possibility of non-reporting bias. We do note, though, that total operative time is the only outcome which includes data from more than 10 studies, so sample size may also affect these results.
Table 3.
RoB 2 bias assessment.
Table 4.
ROBINS-I bias assessment.
| Study | Confounding | Selection | Intervention Classification | Deviation | Missing Data | Measurement of Outcome | Reporting | Overall |
|---|---|---|---|---|---|---|---|---|
| Nicassio et al., 2010 | Serious | Low | Low | Low | Low | Moderate | Moderate | Serious |
| Jonayed et al., 2021 | Moderate | Moderate | Low | Low | Low | Low | Moderate | Moderate |
Table 5.
Newcastle-ottowa scale bias assessment.
| Item (max score) | Schroeder et al., 2011 | Dagistan et al., 2015 | Ulutas et al., 2015 | Agarwal et al., 2016 | Finsterwald et al., 2018 | Sekarek et al., 2020 | |
|---|---|---|---|---|---|---|---|
| A | Selection | ||||||
| Representativeness of exposed cohort (1) | 1 | 1 | 1 | 1 | 1 | 1 | |
| Selection of non-exposed from same community (1) | 1 | 1 | 1 | 1 | 1 | 1 | |
| Exposure ascertained by secure record (1) | 1 | 1 | 1 | 1 | 1 | 1 | |
| Outcome of interest is not present at outset (1) | 1 | 1 | 1 | 1 | 1 | 1 | |
| B | Comparability | ||||||
| Comparability of cohorts (2) | 2 | 2 | 2 | 2 | 2 | 2 | |
| C | Outcome | ||||||
| Assessment of outcome | 1 | 1 | 1 | 1 | 1 | 1 | |
| Adequate follow up period | 1 | 1 | 1 | 1 | 1 | 1 | |
| Adequate follow up of cohorts | 1 | 1 | 1 | 1 | 1 | 1 | |
| Total | 9 | 9 | 9 | 9 | 9 | 9 | |
4. Outcomes
An odds ratio or standardized mean difference was calculated for six outcomes, as detailed below. Additional outcomes included in the analysis were PACU, 24 h, and maximum pain scores, as well as PACU, 24 h, and total narcotic requirement. However, not enough data was collected in these outcomes to produce a meaningful result.
4.1. Total operative time
A total of 11 studies, comprising 2535 patients undergoing lumbar spine surgery, reported the total operative time between cases using general anesthesia and those using spinal anesthesia. Analysis demonstrated a significant difference between general and spinal anesthesia with regards to total operative time. The average operative time was 79 min for operations using SA and 97 min for operations using GA (SMD = −12.62 min, 95% CI -18.65 to −6.59, p < 0.0001). See Fig. 2 for further details.
Fig. 2.
Forest plots for (A) Total operative time, (B) Estimated blood loss, (C) Intraoperative hypotension. Results are presented as follows: green and blue squares represent each studies reported mean difference or odds ratio, respectively. The relate size of the square represents the weight of the study in the meta-analysis. The black diamond represents the calculated overall mean difference or odds ratio.
4.2. Estimated blood loss
A total of 8 studies, comprising 1508 patients undergoing lumbar spine surgery, reported the total estimated blood loss between cases using general anesthesia and those using spinal anesthesia. Analysis demonstrated a significant difference between general and spinal anesthesia with regards to total blood loss. The weighted average EBL across studies was 139 mL for patients undergoing SA and 214 mL for patients undergoing GA. (SMD = −0.57 mL, 95% CI -0.68 to −0.46, p < 0.00001). See Fig. 2 for further details.
4.3. Intraoperative hypotension
A total of 5 studies, comprising 862 patients undergoing lumbar spine surgery, reported the incidence of intraoperative hypotension between cases using general anesthesia and those using spinal anesthesia. Analysis demonstrated no significant difference between general and spinal anesthesia with regards to intraoperative hypotension (OR = 0.76, 95% CI 0.55 to 1.04, p = 0.08). See Fig. 2 for further details.
4.4. Postoperative nausea and vomiting
A total of 8 studies, comprising 1889 patients undergoing lumbar spine surgery, reported the incidence of postoperative nausea and vomiting between cases using general anesthesia and those using spinal anesthesia. Analysis demonstrated a significant difference between general and spinal anesthesia with regards to PONV. The average incidence of postoperative nausea and vomiting was 8% for patients undergoing SA versus 29% for patients undergoing GA. As per Fig. 3, GA patients are 5 times more likely to develop postoperative nausea and vomiting in comparison to SA patients (OR = 0.20, 95% CI 0.15 to 0.26, p < 0.00001). See Fig. 3 for further details.
Fig. 3.
Forest plots for (A) Postoperative nausea and vomiting, (B) Time in PACU, (C) Length of stay. Results are presented as in Fig. 2.
4.5. Time in PACU
A total of 8 studies, comprising 1433 patients undergoing lumbar spine surgery, reported the time spent in PACU between cases using general anesthesia and those using spinal anesthesia. Analysis demonstrated a significant difference between general and spinal anesthesia with regards to time in PACU. The weighted average time in PACU across studies was 103 min for patients undergoing SA versus 93 min for patients undergoing GA (SMD = −0.20 min, 95% CI -0.32 to −0.08, p = 0.0010). See Fig. 3 for further details.
4.6. Length of stay
A total of 9 studies, comprising 2444 patients undergoing lumbar spine surgery, reported the total length of stay between cases using general anesthesia and those using spinal anesthesia. Analysis demonstrated a significant difference between general and spinal anesthesia with regards to total length of stay. The average length of stay was 2.1 days for patients undergoing SA versus 3.4 total days for patients undergoing GA (SMD = −0.14 day, 95% CI -0.18 to −0.10, p < 0.00001). See Fig. 3 for further details.
4.7. Pain scores and PACU narcotic requirement
We planned to include an analysis of PACU, 24 h, and peak pain scores as well as postoperative narcotic requirements in our report. However, granular data was sparse among included studies, preventing meaningful analysis and interpretation.
5. Discussion
Traditionally, general anesthesia has been the anesthetic modality of choice for lumbar spine procedures. Previously, there was a great variability in the operative time, blood loss and invasiveness in these procedures and thus general anesthesia was needed for optimum control over hemodynamic stability, resuscitation, and patient comfort. However, many lumbar spinal procedures have developed standardized minimally invasive alternatives and have otherwise been modified to result in less morbidity and shorter operative times. As such, anesthetic alternatives to general anesthesia have become more and more popular. Spinal anesthesia is one such alternative, and typically relies on intrathecal administration of a combination of sodium channel blockers and narcotic agents. 5 This can be particularly efficacious for patients with significant history of anesthesia reactions or significant cardiopulmonary disease that precludes candidacy for general anesthesia.
The literature, however, has yet to deliver an unequivocal comparison between each method of anesthesia as it relates to lumbar spine surgery. Existing studies are typically retrospective or include small patient samples, and thus have highly variable results. Nonetheless, preliminary literature suggests that SA may have significant clinical utility with respect to intraoperative time, pain, and postoperative nausea and vomiting. For example, a recent meta-analysis from De Cassai et al. have shown that SA is associated with a decrease in early post-operative pain and narcotic requirement, as well as an increase in patient satisfaction. 23 The current meta-analysis adds to existing literature by including large case series as well as randomized control trials. Furthermore, we believe that by limiting analysis to post-2005 publications our review better reflects the current techniques and skillset of surgeons and anesthesiologists practicing today.
This study shows that SA significantly decreases the total operative time of spinal surgeries. Importantly, our study specifically quantified operative time (i.e., incision to closure) as opposed to total anesthesia time or total time in the OR. It is likely that these other variables show even greater decreases in SA procedures, especially as SA has been noted to decrease the time that would otherwise be required for induction and stabilization post-induction. 12 Additionally, preprocedural patient positioning is much less cumbersome without the presence of an endotracheal tube. This also reduces the time required during anesthetic emergence following surgery, which can prolong total operating room time depending on the agents that are utilized. 12,22,24
Spinal anesthesia can also be done outside of the operating room, which can improve throughput and clinical efficiency, as anesthesia can be “induced” while staff members set up operating room equipment. Decreased total operative time is a valuable benefit. As anesthesia setup and recovery can comprise a significant portion of total operating room time, any optimization of anesthetic factors can result in significant improvements in total operating room utilization. One recent work estimated a $36-per-minute value of operating room time, suggesting that utilizing SA can result in notable cost savings. 25 This is supported by previous cost analyses which suggest that operations performed under SA can be up to 40% less costly than those performed by GA. 17,26,27 Beyond cost implications, increased operative time has been linked with higher rates of medical complications, even among patients of comparable procedural complexity. 28,29 In the future, studies should include more detailed data regarding total OR time, operative time, and time spent under anesthesia, as well as peri- and postoperative complications, to fully describe this potential benefit. Likewise, the time benefit of SA should be accounted for in future cost effectiveness analyses.
This study also demonstrates and association between spinal anesthesia and decreased blood loss, length of time in PACU as well as total length of stay. While these results were statistically significant, it is worth noting that their standardized mean differences demonstrate likely indicate lesser clinical difference between SA and GA than their absolute averages would suggest. However, patients undergoing spinal anesthesia were statistically more likely to have higher rates of coronary artery disease and respiratory dysfunction, thus indicating that SA can achieve similar clinical results as GA but in a sicker patient population.
An added benefit of spinal anesthesia is the significant reduction in postoperative nausea and vomiting. As postoperative nausea and vomiting has been tied to physician incentive pay and associated with decreased patient perception of anesthetic quality and recovery, minimizing this postoperative complication is of noteworthy importance. 30,31 Additionally, the lack of prolonged endotracheal intubation and the absence of paralytics in the spinal anesthesia population reduces both the transient throat discomfort and systemic side effects seen in many patients undergoing general anesthesia. Though our study did not investigate postoperative complications, one might hypothesize that SA can result in fewer adverse events related to these findings, particularly postoperative delirium and cognitive decline. 32, 33, 34 This is particularly true for older patients, who are already at high baseline risk for postoperative delirium. 35
This meta-analysis has several limitations. First, heterogeneity of surgery, anesthetic protocols, and outcome measurements confounds the comparison between different studies, introducing bias. This is reflected in the consistently high I2 values across reported outcomes. Our use of a random-effects model for analysis attenuates this weakness. Conversely, the variety of anesthetic techniques represented in our analysis may contribute to the generalizability of our results. Though differing effects for the protocols represented have been reported,36 we argue that our sample size is large enough to minimize the effect of individual anesthetic protocols.
Second, outcomes such as length of stay may be affected by several variables, including surgical complications and co-morbidities, which are often not reported and difficult to distill into comparable measures. Though this work aims to dilute the effect of such granular details through pooled analysis, it does not eradicate it. This important context should be noted.
Furthermore, our analysis does not include some outcomes of interest. Notably, data regarding postoperative pain scores and narcotic requirement was lacking from the included studies. While previous work has shown SA is superior in these areas,23 it is key that future studies continue to investigate this area. Likewise, the cost effectiveness of SA relative to GA will be a key area of interest as SA gains wider adoption. Lastly, there was a notable lack of uniformity amongst surgical techniques. This prevents the authors from identifying the surgical interventions that could see the largest benefit from SA. Nonetheless, this remains one of the largest meta-analyses comparing spinal to general anesthesia for patients undergoing lumbar spine surgery.
6. Conclusion
When compared to general anesthesia, spinal anesthesia can offer improvements in peri- and post-operative metrics and can be applied to patients with significant medical comorbidities. Large series with more granular data on complications, postoperative narcotic usage and pain scores are needed to better characterize the utility of both anesthetic modalities.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors have no competing interests to report. Data used is available upon request.
Disclosures
David Urick: None.
Brandon Sciavolino: None.
Timothy Y. Wang: None.
Dhanesh Gupta: None.
Alok Sharan: consultant fee from Pacira and Paradigm Spine.
Muhammad Abd-El-Barr: receives consultant fee from Spineology, Inc.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.jcot.2022.101923.
Appendix ASupplementary data
The following is the Supplementary data to this article:
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