HMN 2026: How Local and spinal anesthesia emerge as safer alternatives in spine surgery

General anesthesia, once the default choice in spine surgeries, is increasingly giving way to local and spinal anesthesia as the preferred option for eligible patients. Since 2024, surgeons at Singapore General Hospital (SGH) have successfully performed more than 200 spine surgeries with patients remaining awake. While it might sound daunting, this new approach may be a safer option, especially for elderly patients and those with multiple or complex health conditions.

Instead of general anesthesia (GA), which puts patients to sleep, suitable patients can now undergo spinal procedures under light sedation with either local anesthesia (LA) or spinal anesthesia (SA). LA involves injecting numbing medication directly at the site of the procedure, blocking pain signals in a small, targeted area. SA is a technique in which local anesthetic is injected into the fluid-filled space surrounding the spinal cord, numbing the body from the chest down. Both non-GA options eliminate the need to insert a breathing tube into the windpipe or use mechanical ventilation, while allowing patients to breathe comfortably on their own.

The team from SGH’s Department of Orthopaedic Surgery and Department of Anaesthesiology conducted a matched-control cohort study that evaluated and compared the perioperative anesthesia and surgical outcomes of 44 SGH patients, ages 18 and older, who had endoscopic lumbar spine surgery between 2023 and 2024 for narrowed spinal passages. Half received GA, and the other half remained awake under SA. These surgeries typically last between 60 and 120 minutes, and study findings showed that the GA cohort was more likely to experience drops in blood pressure and slower heart rates during surgery, which can be dangerous if not addressed quickly.

Dr. He Yingke, a consultant in SGH’s Department of Anaesthesiology and co-corresponding author, helped develop the anesthetic protocols underpinning the program. She noted, “Patients may be surprised and worried to learn they will not be put to sleep. However, they are, in reality, comfortably sedated throughout the procedure. Without general anesthesia, they generally experience less postoperative nausea and vomiting and an earlier return to mobility, which aids the recovery process.”

The study also found that the amount of opioids used for pain control during and after surgery was significantly lower in the non-GA group. High opioid consumption carries short-term risks such as breathing problems and longer-term concerns such as dependency or addiction.

Dr. Jiang Lei, a consultant in SGH’s Department of Orthopaedic Surgery and co-corresponding author of the study, said, “By combining endoscopic surgical techniques with spinal anesthesia, we can minimize both surgical and anesthetic stress on patients. Many can get out of bed and walk around within hours after surgery and experience fewer opioid-related complications such as low blood pressure or delirium. This is especially relevant as Singapore faces an aging population, giving rise to more age-related spinal disorders and other comorbidities that make surgery under GA challenging. Awake spine surgery offers an opportunity to expand access to surgical treatment for this group of patients.”

Besides narrowed spinal passages, spine surgeries can address conditions such as slipped disks and worn-out spinal cushions, either by relieving pressure on nerves (decompression) or joining vertebrae together (fusion) to stabilize the spine. At SGH, awake spine surgery has since been expanded to include endoscopic decompression (performed through micro-incisions) and minimally invasive fusion surgeries.

Associate Professor Reuben Soh, senior consultant in SGH’s Department of Orthopaedic Surgery and director of spine surgery, sees awake spine surgery as part of a broader shift in how surgery is delivered: “Spinal surgeries can now be done with fewer risks and faster recovery. Patients are up and walking within hours, and many can go home on the same day. Having performed more than 200 awake spine surgeries with no conversions to GA, we believe this approach has the potential to extend surgical treatment to more patients, including those previously considered too high-risk for general anesthesia.”

The study results were published in the journal Clinical Spine Surgery on April 22, 2026, in a paper titled “Perioperative Outcomes in Endoscopic Lumbar Decompression Surgery Under Spinal and General Anesthesia: A Matched Control Cohort Study.”

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