Awake Local Anesthesia Versus General Anesthesia in Anterior Cervical Discectomy and Fusion: a Propensity Matched Analysis Utilizing a National Surgical Registry

Introduction: A rising trend of awake spinal procedures has been observed recently as they may provide reduced financial burdens on patients, faster recovery times, and better outcomes. The aim of this study was to assess the non-inferiority of surgical outcomes between patients who underwent anterior cervical and discectomy (ACDF) under awake local anesthesia versus general anesthesia (GA).

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing ACDF from 2011-2020. Propensity score matching was employed to match patients who underwent awake ACDF to their counterparts who underwent ACDF under GA on a 1:4 ratio. The outcomes of interest included postoperative complications, nonroutine discharge, 30-day readmissions, and 30-day reoperations. The non-inferiority of awake local anesthesia compared with GA was defined as a risk difference of < 10.0% at a one-sided 97.5% confidence interval.

Results: In propensity match analyses, a total of 470 patients were included, of which 94 (20%) patients underwent awake ACDF, and the remainder underwent ACDF under GA. The mean age of the cohort was 56.4 ± 11.3 years old, and 249 (53.0%) were female. Baseline characteristics, including age, sex, and comorbidities, were similar among the two groups. In the awake group, 2.1% of the patients were discharged to a non-routine destination, compared to 4.8% in the GA group (p=0.252). Thirty-day readmission was observed in 1.1% and 3.7% for the awake and GA groups, respectively (p=0.189). Furthermore, none of the patients in the awake group underwent reoperation, compared to 1.3% of the GA group (p=0.261). Non-inferiority of awake ACDF compared to ACDF under GA was demonstrated at a risk difference of 10% for non-routine discharge, readmission, and reoperation.

Conclusion : ACDF under awake local anesthesia demonstrated similar early postoperative outcomes compared to ACDF under GA. Noninferiority in surgical outcomes after surgery was noted between the two procedures, suggesting that awake ACDF constitutes a viable treatment option for patients who cannot tolerate GA.