Journal of Clinical Anesthesia 46 (2018) 3–7

Contents lists available at ScienceDirect

Journal of Clinical Anesthesia

Original Contribution

Spinal versus general anesthesia for lumbar spine surgery in high risk
patients: Perioperative hemodynamic stability, complications and costs
Michael Finsterwald, MD a,⁎, Marco Muster, MMed b, Mazda Farshad, MD, MPH a, Andrea Saporito, MD, MHA c,
Muriel Brada, MMed b, José A. Aguirre, MD, MSc b
a
Department of Orthopedic Surgery, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland
b
Division of Anesthesiology, Balgrist University Hospital, Forchstrasse 340, 8008 Zurich, Switzerland
c
Anesthesiology Department, Bellinzona Regional Hospital, 6500 Bellinzona, Switzerland

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

Article history: Objective: More stable perioperative hemodynamic conditions, lower costs and a lower perioperative complica-
Received 6 November 2017 tion rate were reported in young healthy patients undergoing lumbar spine surgery in spinal anesthesia (SA)
Received in revised form 19 December 2017 compared to general anesthesia (GA). However, the benefits of SA in high risk patients (ASA ≥ II suffering from
Accepted 4 January 2018 cardiovascular and/or pulmonary pathologies) undergoing this surgery are unclear. Our objective was to analyze
Available online xxxx
whether SA leads to an improved perioperative hemodynamic stability and to a more cost-effective management
compared to GA in high risk patients undergoing this surgery.
Keywords:
Spinal anesthesia
Methods: In a retrospective analysis 146 ASA II-III patients who underwent lumbar spine surgery in SA were com-
Lumbar spine surgery pared with 292 ASA I-III patients who were operated in GA between 2000 and 2014. Hemodynamic effects, hos-
High risk patients pitalization times, complications, and costs according to the Swiss billing system were assessed. The data
Hemodynamic stability extraction was conducted according to Strengthening the Reporting of Observational Studies in Epidemiology
Costs (STROBE) initiative for cohort studies.
Results: The patients in the SA group were older (75 years (±9.6) vs 69 (±11.5), p b 0.001), had a lower BMI
(25.8 kg/m2 (±4.8) vs 27.2 (±4.7), p = 0.003) and showed a higher ASA score (3 vs 2, p b 0.001). However,
SA was associated with significantly better perioperative hemodynamic stability with less need for intraoperative
vasopressors (15% vs 57%, p b 0.001), volume supplementation (1113 ml ±458 vs 1589 ± 644, p b 0.001) and
transfusions (0% vs 4%, p b 0.001). Additionally, the number of hypotension episodes was lower in the SA
group (15% vs 47%, p b 0.001). Furthermore, the SA group showed a significantly shorter duration of surgery
(70 min (± 1.2) vs 91 (± 41), p b 0.001), lower postoperative nausea and vomiting (PONV) (4% vs 28%, p b
0.001) and pain in the post anesthesia care unit (PACU) (visual analogue scale (VAS) 2.3 (±1.1) vs 0.8 (±0.8),
p b 0.001), whereas pain after 24 h did not differ (VAS 0.9 (±1) vs 0.8 (±1.1), p = ns). The postoperative com-
plication (7% vs 5%, p = 0.286) and revision rates (4% vs 5%, p = 0.626) were similar in both groups. Total costs
(United States Dollars (USD) 6377 (±2332) vs 7018 (±4056), p = 0.003) and PACU time were significantly
lower in the SA group (35 min (±12) vs 109 (±173), p b 0.001).
Conclusions: Lumbar spine surgery in cardiovascular high risk patients with SA is safe, allows good perioperative
hemodynamic stability and might lead to lower health care costs. Further prospective studies are needed to con-
firm these findings.
© 2018 Elsevier Inc. All rights reserved.

1. Introduction

The increasing proportion of elderly patients and their comorbidities

⁎ Corresponding author at: Department of Orthopedic Surgery, Balgrist University
Hospital, Forchstrasse 340, CH-8008 Zurich, Switzerland.
E-mail addresses: michi.finsterwald@sunrise.ch (M. Finsterwald),
marco.muster@swissonline.ch (M. Muster), mazda.farshadtabrizi@balgrist.ch
(M. Farshad), andrea.Saporito@eoc.ch (A. Saporito), murieldiana.brada@balgrist.ch
(M. Brada), jose.aguirre@balgrist.ch (J.A. Aguirre).
[35] have modified the perioperative risk profile and perioperative he-
modynamic and cardio-pulmonary stability have become of pivotal im-
portance [13]. Spinal anesthesia for lumbar spine surgery has been
associated with a greater hemodynamic stability compared to general
anesthesia [18]. However, these findings are controversially discussed
by other authors [29]. Additionally, the increasing economical restraints
force hospitals to increase their productivity by lowering procedure-

https://doi.org/10.1016/j.jclinane.2018.01.004
0952-8180/© 2018 Elsevier Inc. All rights reserved.
4 M. Finsterwald et al. / Journal of Clinical Anesthesia 46 (2018) 3–7
specific costs and avoiding complications [31,37]. Regional anesthesia
has been shown to reduce perioperative costs by reducing drug con-
sumption, decreasing or bypassing PACU stay and allowing earlier am-
bulation. [30,32,33,44] Furthermore, multiple studies have shown that
spinal anesthesia might lead to a reduction in analgesic use, shorter an-
esthesia and surgery time, reduced blood loss, less PONV, a lower com-
plication rate and reduced costs [1,5,17,18,22,29,36,41,42]. However,
some possible drawbacks of spinal anesthesia like longer PACU stay
and lower surgeon satisfaction have also been reported [18,22].
To our knowledge, the impact of spinal anesthesia for lumbar spine
surgery on hemodynamic stability and costs has not been analyzed in
high risk patients [11]. The aim of this retrospective study was to ana-
lyze these outcomes comparing a cardiovascular or pulmonary high
risk (ASA ≥ II suffering from cardiovascular and/or pulmonary patholo-
gies) population which in our institution is usually operated in spinal
anesthesia with a relatively low risk population usually operated in gen-
eral anesthesia for lumbar spine surgery.
2. Methods
After approval by the Ethical Committee (Kantonale
Ethikkommission des Kantons Zürich, EK: 2015-0526) we retrospec-
tively analyzed the medical charts of all patients undergoing lumbar
spine surgery in the period 01.01.2000 – 31.12.2014. To avoid selection
bias we checked all patients with lumbar spine surgery during this peri-
od and extracted 146 patients who underwent surgery with spinal an-
esthesia (SA). We compared these patients to a group of 292 patients
operated in the same time period in general anesthesia (GA) (Fig. 1).
5330 lumbar spine surgeries in GA
Identification
identified in database
5476 patient records screened
Screening
Inclusion
438 records included in
statistical evaluation
GA = general anesthesia; SA = spinal anesthesia
Fig. 1. Flowchart according to the STROBE guidelines.
The data extraction was conducted according to Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE) initiative
for cohort studies. Our inclusion criteria were adult patients of both
sexes undergoing elective lumbar spine surgery of a duration of
b90 min. For the SA group this surgery was performed in spinal anes-
thesia due to a cardiovascular and/or pulmonary high risk situation
(ASA II-IV). General anesthesia was performed for any ASA category
(ASA I-III). Exclusion criterion was the written patient refusal to use
her/his records for research. Our primary outcome was the hemody-
namic stability (hypotension episodes, intraoperative vasopressor/vol-
ume use). Additionally, we compared costs, perioperative anesthetic/
surgical complications, blood loss, pain (at PACU arrival and at 24 h),
length of PACU stay, length of hospitalization and the revision rate. All
surgeries were performed by a spine fellow or a staff surgeon and all
data were collected, collated and analyzed by four independent
researchers.
After intravascular access and standard monitoring (electrocardiog-
raphy, non-invasive blood pressure monitoring and peripheral oxygen
saturation monitoring) spinal anesthesia was performed in the lateral
decubitus position using plain bupivacaine 0.5% (5–10 mg) with imme-
diate positioning first into the supine position until a sensory level be-
tween T6 to T8 was achieved. Then, patients were turned into the
prone, flat position. Oxygen administration was provided by nasal can-
nula at a flow of 2 l/min. Mild to moderate sedation defined according to
Standards, Guidelines and Statements of the American Society of Anes-
thesiologists [4] was performed using a propofol and remifentanil
targeted-controlled infusion (TCI). Sedation depth was monitored
using the modified Observer's Assessment of alertness/sedation scale
146 lumbar spine surgeries
performed in SA according to
anesthesia records
- 4480 records excluded as primary
spondylodesis, scoliosis surgery or
thoraco-lumbar intervention
- 152 records excluded as no written
research consent present
- 406 records excluded as surgery time
scheduled > 90 min
 M. Finsterwald et al. / Journal of Clinical Anesthesia 46 (2018) 3–7
(OAAS; score 4 (lethargic responses to name in normal tone) corre-
sponds to mild sedation, score 3 (responds only after name is called
loudly and/or repeatedly) corresponds to moderate sedation level) [15].
General anesthesia was induced and maintained using propofol and
remifentanil TCI with additional fentanyl for analgesia according to
patient's need. Neuromuscular relaxation was provided with
rocuronium according to neuromuscular monitoring. The inspired oxy-
gen fraction (FiO2) varied between 30 and 50% according to patient's
need and endexpiratory CO2 (ETCO2) levels were maintained between
35 and 45 mm Hg. The prone position was adopted as soon as possible
in the case of hemodynamic stability. Treatment for cardiovascular
problems was according anesthesiologist's choice using vasopressors
and/or volume.
All patients were discharged with spontaneous breathing to the
PACU with 2 l/min oxygen through a nasal cannula.
Hypotension was defined as a decrease in the systolic blood pressure
(SAP) of 20% or more from the preoperative blood pressure at baseline
(prior to anesthesia induction) for more than one minute [7]. The
amount of vasopressors used and volume of fluids infused intraopera-
tively was recorded.
Surgical time (time from incision to placement of the surgical dress-
ing) was documented. To calculate a theoretical PACU bypass according
to the data registered we used an established score which incorporates
the essential elements of the modified Aldrete system (usual score for
PACU discharge), [3] as well as an assessment of pain and emesis.
PACU bypass was considered possible if a score of ≥ 12 was achieved
(with no score b 1 in any individual category) [43]. The standard criteria
for PACU discharge according to our protocol were VAS b 30 (on a scale
0 to 100), bilateral regression of sensory block below T10 level and a
modified Aldrete score of ≥9 [3].
The recorded postoperative variables included heart rate and systol-
ic arterial pressure on admission into the PACU and every 10 min there-
after until discharge. Patient complaints of pain or nausea/vomiting and
the corresponding treatment were recorded. Total stay in the PACU and,
after transfer to the ward, the length of hospital stay (LOS) was assessed.
Postoperative complications including spinal headache, urinary reten-
tion, pulmonary dysfunction (respiratory insufficiency, hypoxia, pneu-
monia), gastrointestinal dysfunction and neurologic impairment, were
examined in both groups. The patient records were assessed until the
6 months postoperative clinical follow up.
For the costs calculation we included the fix costs and personnel
costs in the operating theatre (OR), PACU and ward (top-down tech-
nique) and used the following values: operating room costs: USD
27.21/min; PACU costs: USD 2.43/min; ward nursing costs: USD 1.66/
min and ward hotel costs (catering, cleaning, laundry: non-medical
ward costs): USD 103.36/day. Due to the minimal changes in the fix
costs in the Swiss health system during the studied time frame, no
Table 1
Demographic profile and associated comorbidities of the patients.
Variables Group GA (n = 292)
Age (y) 69 ± 11.5
Gender (m:f) 146:146
BMI (kg/m2) 27.2 ± 4.7
Surgery 1–2 level lumbar decompression
Comorbidities (%/n)
- Art. hypertension 39% (n = 113)
- CAD 21% (60)
- Valv. HD 3% (8)
- PAD 7% (20)
- CVD 7% (20)
- COPD/rest. PD 12% (36)
- DM 23% (68)
- CRI 11% (32)
GA = general anesthesia; SA = spinal anesthesia; BMI = body mass index; CAD = coronary artery disease; Valv. HD = valvular heart disease; PAD = peripheral arterial occlusive disease;
CVD = cerebrovascular disease; COPD/rest. PD = chronic obstructive pulmonary disease/restrictive lung disease; DM = diabetes mellitus; CRI = chronic renal insufficiency.
5
adjustments to inflation rate were undertaken as it would not influence
the cost difference between the groups.
2.1. Statistical analysis
Unpaired t-test was used for parametric data null hypothesis testing,
whereas Mann-Whitney U test was applied to nonparametric data. A p-
value b 0.05 was considered statistically significant (95% confidence in-
terval). Results are shown as means and standard deviations for normal-
ly distributed parameters and medians for not normally distributed
parameters. Statistical analysis was performed using SPSS (IBM, USA)
and Numbers ‘09 2.1 version (Apple Inc., USA) software.
3. Results
The patients and surgical characteristics are shown in Table 1. Sur-
gery was successfully completed in all cases and no spinal anesthesia
had to be converted into general anesthesia. Overall, the patients in
the SA group were older, had a lower BMI and showed a higher ASA
score. (Tables 1 & 2) Lumbar decompression surgery of 1–2 levels was
performed in all patients of the GA group and in 93% (n = 136) of the
SA group. Eight patients in the SA group had a 3–4 level decompression
and 2 patients required additional instrumentation. (Table 1).
The hemodynamic alterations were more accentuated in the GA
group which was associated to a higher number of hypotension epi-
sodes, a higher use of vasopressors and more volume supplementation
compared to the SA group. Blood loss did not differ significantly be-
tween the groups but more transfusions were performed in the GA
group. Spinal anesthesia was associated to significantly shorter duration
of surgery, lower postoperative PONV and pain during the PACU stay,
whereas pain after 24 h did not differ between the groups (Table 3).
The postoperative complication and revision rate were similar in
both groups. Revision surgery was done for postoperative hematoma
(SA: 3% (4/146) vs GA: 4% (11/292)), dural tear (SA: 1% (1/146) vs
GA: 1% (3/292)) and for one recurrent disc herniation with neurological
symptoms in the SA group and one spondylodiscitis in the GA group.
(Table 4).
The theoretical PACU bypass rate was higher in the SA group. More-
over, PACU time was significantly shorter in the SA group which was as-
sociated to reduce total costs compared to the general anesthesia group.
Length of hospital stay did not differ between the groups. (Tables 3 & 5).
4. Discussion
Spinal anesthesia and general anesthesia are both reasonable anes-
thetic approaches for lumbar spinal surgery and there seems to be no
clearly superior technique in terms of morbidity and mortality. [8,11]
Group SA (n = 146) p-Value
75 ± 9.6 p b 0.001
82:64 p b 0.001
25.8 ± 4.8 p = 0.003
1–2 level lumbar decompression
(7 × 3 level, 1 × 4 level, 2× instrumentation)
77% (n = 112)
49% (71)
12% (18)
18% (26) all p b 0.05
12% (18)
35% (51)
61% (89)
36% (53)
6 M. Finsterwald et al. / Journal of Clinical Anesthesia 46 (2018) 3–7

Table 2 Table 4
ASA status. Complications.

Variables Group GA (n = 292) Group SA (n = 146) p-Value Variables Group GA Group SA p-Value
(n = 292) (n = 146)
ASA-Score 2 3 p b 0.001
ASA 1: n = 41 ASA 2: n = 50 Wound problems/hematoma 2% (7/292) 5% (8/146) p = 0.286
ASA 2: n = 171 ASA 3: n = 96 Dural tear 1% (3/292) 0.7% (1/146) p = ns
ASA 3: n = 30 Spondylodiscitis 0.3% (1/292) – p = ns
Recurrent disc herniation – 0.7% (1/146) p = ns
ASA = American Society of Anesthesiologists; GA = general anesthesia; SA = spinal
Surgical revision rate 5% (15/292) 4% (6/146) p = 0.626
anesthesia.

However, the studies reviewed by De Rojas et al. [11] and the studies of hypertension as seen under GA [17,18] which can increase blood loss.
published thereafter [1,18,36,41,42] mostly included ASA I-II patients However, due to the retrospective design of our study, the use of vaso-
and did not focus on cardiovascular and/or pulmonary high risk pa- pressors, volume and blood management were not standardized. This
tients. Although, in most of the above mentioned studies a greater he- might have led to treatment of hypotension with volume leading to co-
modynamic stability was found in the SA groups. [11] Only the agulation disorders or dilution with the need for transfusion. Therefore,
randomized controlled study by Sadrolsadat et al. [29] showed more possible associations concerning transfusion to the anesthesia regimen
perioperative hypotensive events in the SA group (24%) compared to have to be taken with a pinch of salt.
the GA group (12%, p b 0.001) with no difference in the episodes of in- The existence of a residual sensory blockade after SA might be an ex-
traoperative bradycardia. However, there was no difference in the intra- planation for less postoperative pain in the SA group [5] which has also
operative blood loss and need for fluids between the groups. New been described by other authors [5,10,17,18,22,23]. Additionally, de-
evidence suggests that perioperative hemodynamic stability might creased pain scores in the SA group might be due to regional
have an impact on patient outcome. [2,13,26,34] Moreover, anemia, anesthesia's more selective inhibition of afferent nociceptive sensitiza-
hypoxemia, increased myocardial oxygen demand, ventricular overload tion pathways [5,16].
or underload, systolic or diastolic dysfunction and neuroendocrine re- We could show that the incidence of PONV is lower in the SA group,
sponses to the stresses of surgery all contribute to the decreased ische- which is in accordance with other studies [11,25]. A possible explana-
mic cardiac threshold early after surgery. [21] Therefore, the impact of tion is that gastric emptying is inhibited by GA leading to increased nau-
the anesthesia chosen for cardiovascular high risk patients is of utmost sea and vomiting. [24].
importance [9]. According to current literature, improved hemodynam- We found no differences in the number of surgical complications be-
ic stability of regional anesthesia (RA) over GA might be a result of intra- tween the groups and the rate of incidental durotomy is in accordance
operatively inhibited release of stress hormones, leading to less with previous publications [38,40].
elevation and fluctuations of the mean arterial pressure and heart rate With the chosen top down technique we assumed that standardized
[5,6]. Additionally, the use of plain bupivacaine as in our study has spinal- and general anesthesia procedures would need the same
been shown to improve hemodynamic stability compared to hyperbaric amount of time for successful induction with insignificant cost differ-
bupivacaine [39]. Interestingly, our study shows a greater hemodynam- ence between the drugs used. However, this fact is controversially
ic stability with less vasopressor and volume requirement in the SA discussed in the current literature [5,22,23,29]. The most important
group despite the fact, that this group included high risk patients com- cost-saving factor was the reduced PACU time, which has also been de-
pared to the healthier GA group. Additionally, the need for transfusion scribed [12]. However, other studies did not report a difference in the
was lower in the SA group. However, all transfusions in the GA group PACU time comparing SA to GA which mainly depends on the local an-
were performed in ASA III patients. esthetic (long-lasting vs short-acting), its dosage and baricity, the tech-
This positive impact of SA on blood loss during lumbar spinal surgery nique (unilateral spinal anesthesia) used for SA and the discharge
has previously been described. [5,17,18] It has been argued that RA criteria (defining spontaneous voiding as a discharge criteria or not)
leads to decreased blood loss because of vasodilation and hypotension [5,29]. The faster PACU time did not translate into earlier discharge
caused by RA's sympathetic blockade while maintaining spontaneous home time in our study which is also in accordance with other studies
ventilation, which leads to lower intrathoracic pressure and, as a result, [5,28]. Cost analysis of previous authors show that SA has an important
less distension of epidural veins [19,27]. This observation has been also positive effect on costs reducing operating costs, indirect costs and total
reported in other studies for lumbar spine surgery [5,12,14,17,20]. Addi- costs due to shorter hospital stay, shorter duration of anesthesia, shorter
tionally, the better intraoperative hemodynamic stability avoids phases duration of operation and lower estimated blood loss [1,18,36,41,42].
Due to the experience in our department and the results of this ret-
rospective study, we recommend the use of spinal anesthesia for spine
Table 3 surgery with a duration of b90 min in patients with cardiovascular
Intraoperative and postoperative variables.
risk factors (arterial hypertension, coronary artery disease, peripheral
Variables Group GA Group SA p-Value arterial occlusive disease, diabetes mellitus with renal/vascular compli-
(n = 292) (n = 146) cations, cerebrovascular disease with or without history of stroke) and/
Duration of surgery (min) 91 ± 41 70 ± 1.2 p b 0.001 or pulmonary risk factors (chronic obstructive pulmonary disease or
Hypotension 47% 15% p b 0.001
Vasopressor use (% of cases) 57% 15% p b 0.001
Crystalloids administered (ml) 1589 ± 644 1113 ± 458 p b 0.001 Table 5
Blood loss (ml) 226 ± 170 177 ± 159 p = 0.003 Comparison of costs.
Transfusion rate 4% 0% p b 0.001
Variables Group GA (n = 292) Group SA (n = 146) p- value
VAS PACU 2.3 ± 1.1 0.8 ± 0.8 p b 0.001
VAS 24 h 0.8 ± 1.1 0.9 ± 1 p = 0.781 Cost OR (USD) 3463 (±1560) 2894 (±457) p b 0.001
PONV 28% 4% p b 0.001 Cost PACU (USD) 264 (±420) 84 (±29) p b 0.001
PACU time (min) 109 ± 173 35 ± 12 p b 0.001 Cost ward (USD) 3291 (±2075) 3400 (±1847) p = 0.591
PACU bypass (theor.) 0.7% 89% p b 0.001 Cost total (USD) 7018 (±4056) 6377 (±2332) p = 0.003
LOS (d) 8.4 8.2 p = 0.590
GA = general anesthesia; OR = operating room; PACU = post anesthesia care unit; SA =
GA = general anesthesia; SA = spinal anesthesia; VAS = visual analogue scale (0−10); spinal anesthesia.
PACU = post anesthesia care unit; PONV = postoperative nausea and vomiting; LOS = Costs were converted to USD at a conversion rate of 1 CHF (Swiss Franc) = 1.02 USD (US
length of (hospital) stay. Dollar).
 M. Finsterwald et al. / Journal of Clinical Anesthesia 46 (2018) 3–7
restrictive lung disease) with the aim to keep stable hemodynamic con-
ditions and to avoid intubation and mechanical ventilation.
Our study has some drawbacks. The retrospective study design has
tendency for bias.
The differences in the two population concerning age and ASA score
derive from the fact, that higher ASA scores are often older patients and
that in our institution we suggest SA in patients with ASA ≥ II due to car-
diovascular and/or pulmonary pathologies to avoid cardiovascular/pul-
monary complications. This made matching of risk class and age
impossible. Additionally in a high risk patient anesthetist and surgeon
assigned to the case may be more senior resulting in faster completion
of the surgical procedure and thus, the shorter surgical duration. More-
over, the experience of the surgeons certainly increased with the case
load considering the number of years studied. This might have influ-
enced the results comparing patients undergoing surgery at the begin-
ning or at the end of the studied time period. The long time frame
studied, small amount of patients operated in spinal anesthesia and
the spread of cases over the period of time did not allow for a detailed
analysis of this fact.
5. Conclusion
To conclude we can state that the use of SA for lumbar spine surgery
in cardiovascular high risk patients is safe and allows good perioperative
hemodynamic stability leading to less anesthesia-related complications
as well as facilitating PACU bypass or shortening PACU stay duration.
This could have a positive impact on health care costs. However, pro-
spective, randomized controlled studies on this patient population are
needed to confirm our findings.
Disclosure
The authors have nothing to disclose. This research did not receive
any specific grant from funding agencies in the public, commercial, or
not-for-profit sectors.
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