Establishing the Viability of Awake Spine Surgery in Parkinson’s Disease Patients

Introduction: The use of general anesthesia (GA) in Parkinson’s Disease (PD) patients remains contentious. GA in PD patients has been associated with masking intraoperative Parkinsonian exacerbations; PD-specific drug-drug interactions; primary parkinsonism symptoms when used in combination with adjunctives (eg opioids); increased postoperative nausea/vomiting (PONV), postoperative complications, and length of stay; and potentially precipitation of cognitive decline. The transition towards minimally invasive outpatient awake spine surgeries has allowed for the facilitation of spine surgery in historically poor surgical candidates. In this study, the first of its kind, we aim to establish the viability of awake spine surgery using spinal anesthesia (SA) in PD patients.

Methods: Case logs of two surgeons at two institutions were reviewed and PD patients having undergone awake spine surgery under SA were identified. ASA score, anesthesia and adjunctive anesthesia, procedure duration, blood loss, surgery complications, length of stay, discharge time, time to ambulation, opioid use, postoperative nausea and vomiting, 30-day readmission, and pain scores were collected.

Results: 13 PD patients ages 69.6±4.4y were identified as having received single-level awake spine surgeries under SA with a 2:11 ratio of fusions to decompressions. Mean ASA score was 2.9±0.3. Average procedure duration was 135.5min for fusions and 54.9±22.5min for decompressions. Blood loss was minimal across all surgeries. No adverse events or complications were noted, with PONV in 4 (31%) patients. Average return-to-ambulation time was 3 days in fusions and 0 days in decompressions. Average PACU-to-discharge time was 77 hours for fusions and 3.1±2.9 hours for decompressions. Postoperative morphine use was 9.23±7.66mme across all patients, with 6 (46%) receiving 0mme. There were no 30-day readmissions.

Conclusion : Strong viability is indicated for SA-based awake spine surgery in PD patients. Further investigation through randomized controlled trials evaluating anesthetic approaches in PD patients is needed.