General anaesthesia, once the default choice in spine surgeries, is increasingly giving way to local and spinal anaesthesia as the preferred option for eligible patients.
Since 2024, surgeons at Singapore General Hospital (SGH) have successfully performed more than 200 spine surgeries while patients remain 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 anaesthesia (GA) which puts patients to sleep, suitable patients can now undergo spinal procedures under light sedation with either local anaesthesia (LA) or spinal anaesthesia (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 where local anaesthetic 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 and mechanical ventilation, while allowing patients to breathe on their own comfortably.
The team from SGH’s Department of Orthopaedic Surgery and Department of Anaesthesiology conducted a matched control cohort study, evaluating and comparing the perioperative anaesthesia and surgical outcomes of 44 SGH patients, aged 18 and above, who had endoscopic lumbar spine surgery between 2023 and 2024 for narrowed spinal passages. Half of them were under GA and the other half remained awake under SA. These surgeries typically last between 60-120 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, Consultant, Department of Anaesthesiology, SGH, and co-corresponding author helped develop the anaesthetic protocols underpinning the programme. 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 anaesthesia, 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. A high opioid consumption carries short-term risks like breathing problems and longer-term concerns such as risk of dependency or addiction.
Dr Jiang Lei, Consultant at the Department of Orthopaedic Surgery, SGH and co-corresponding author of the study, said: “By combining endoscopic surgical techniques with spinal anaesthesia, we can minimise both surgical and anaesthetic 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 ageing 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 discs, and worn-out spinal cushions, either by relieving pressure on nerves (decompression) or joining vertebrae together (fusion) to stabilise the spine. At SGH, awake spine surgery has since been expanded from minimally invasive to include endoscopic decompression, and minimally invasive fusion surgeries.
Assoc Prof Reuben Soh, Senior Consultant, Department of Orthopaedic Surgery, and Director of Spine Surgery, SGH, sees awake spine surgery as part of a broader shift in how surgery is delivered, ”Spinal surgeries can now be done with much 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 conversion 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 anaesthesia."
The study results were published in peer-reviewed journal Clinical Spine Surgery on 22 April 2026, in a paper titled "Perioperative Outcomes in Endoscopic Lumbar Decompression Surgery Under Spinal and General Anesthesia: A Matched Control Cohort Study" (DOI: 10.1097/BSD.0000000000002088).
