HonorHealth Deer Valley Medical Center recently performed its first awake spine surgery, a minimally invasive L4-L5 transforaminal lumbar interbody fusion (TLIF), using spinal anesthesia with light sedation rather than general anesthesia and intubation. The patient, who had severe lung disease and was considered high-risk for traditional surgery, underwent the procedure successfully, expanding treatment options for patients who may not otherwise be surgical candidates.
Rory Murphy, MD, neurosurgeon and affiliated HonorHealth Medical Staff member at the Bob Bové Neuroscience Institute, led the effort and spoke with the service line about what it took to make it happen.
Why awake?
For patients with significant pulmonary comorbidities, avoiding intubation and mechanical ventilation can reduce respiratory complications and support a smoother recovery. Older patients may also avoid some of the cognitive effects, like postoperative delirium, associated with deep anesthesia.
"The most immediate difference is how quickly patients recover in the hours after surgery," Dr. Murphy said. "Patients typically wake up very quickly and clearly. Because they have not been intubated and don‘t require deep anesthetic agents, they often avoid many of the common postoperative issues we see with general anesthesia such as nausea, grogginess and respiratory irritation."
Spinal anesthesia also provides excellent early postoperative pain control, helping patients mobilize sooner and recover more comfortably.
What if the patient wakes up mid-procedure?
Patients are technically conscious throughout the procedure but are kept comfortable with spinal anesthesia and carefully controlled sedation. Most patients rest quietly during surgery and do not experience pain.
"If a patient becomes more alert or uncomfortable, the anesthesia team can easily deepen sedation for a period of time," Dr. Murphy noted. "Because we aren’t relying on deep general anesthesia, adjustments can be made very quickly. In practice, patient comfort is excellent and this scenario is rarely problematic."
Where the complexity lives
For this patient with severe lung disease, the risks of general anesthesia outweighed the added complexity of the awake approach.
"The added complexity primarily falls on the anesthesia team," Dr. Murphy said, "although the surgeon must also work efficiently and precisely within a minimally invasive approach."
The procedure involved:
- Anesthesiologist: Managing spinal anesthesia and carefully titrated sedation
- Surgeon: Performing the minimally invasive TLIF procedure
- Neuromonitoring team: Monitoring neural function throughout
- Circulating nurse and scrub tech: Supporting workflow and maintaining sterility
- Surgical assistant: Assisting with exposure, instrumentation and closure
Compared with a standard TLIF under general anesthesia, the key difference is the level of communication required among the surgical and anesthesia teams.
"There’s constant communication between the surgeon, anesthesia team and operating room staff to make sure the patient stays comfortable and everything runs smoothly," Dr. Murphy said. "When that coordination works well, as it did in this case, it allows us to deliver a complex spine procedure in a way that can significantly improve the patient's early recovery."
What this means for physicians and APPs
This case demonstrates how minimally invasive spine surgery may be offered to select patients whose medical comorbidities previously made surgery too risky. While not appropriate for every patient, awake spine surgery can expand treatment options for individuals with significant pulmonary disease or other anesthetic risk factors.