Reconsidering Anesthesia in Lumbar Surgery: An Umbrella Review of Awake Versus General Anesthesia

Background/Objectives: Lumbar degenerative disease drives numerous elective spine surgeries, and anesthetic choice significantly influences airway risk, hemodynamics, analgesia, mobilization, and recovery. Interest in awake lumbar surgery, typically using spinal anesthesia (SA) with light sedation, has grown as comparative studies suggest comparable safety to general anesthesia (GA) with potential reductions in opioid use, nausea, time to ambulation, and efficiency metrics. However, these benefits may be context-dependent under standardized perioperative care. Therefore, the aim of this umbrella review is to synthesize previously published meta-analyses that compare postoperative outcomes between SA and GA in patients undergoing lumbar spine surgery. Methods: A systematic literature search was executed with defined criteria across PubMed, Embase, and Web of Science. Data analysis was performed using the metaumbrella R package to report equivalent Hedges' g values. Each meta-analysis was evaluated with the AMSTAR2 tool, and the credibility of the evidence was determined with Ioannidis criteria. Results: Seven meta-analyses were included. Pooled data showed that SA was associated with shorter operative time, reduced length of stay, and lower intraoperative blood loss, supported by class III credibility for operative time and length of stay and class IV for blood loss in the setting of high between study heterogeneity. SA was also associated with lower odds of postoperative nausea and vomiting and reduced postoperative analgesic requirements, both graded as class IV with prediction intervals that encompassed the null. Intraoperative hypotension and bradycardia did not differ significantly between SA and GA, and postoperative pain scores and overall complication rates were similarly neutral. Conclusions: This umbrella review identifies potential advantages of SA in lumbar spine surgery, including shorter operative time, reduced length of stay, lower intraoperative blood loss, and lower postoperative nausea and analgesic requirements, while finding no consistent differences in hemodynamic events or overall complications. These findings suggest SA as an alternative pathway to general anesthesia for selected lumbar procedures but highlight substantial heterogeneity and low-to-intermediate credibility for several endpoints, underscoring the need for additional high-quality, protocolized comparative studies to refine effect sizes and define optimal patient and procedural selection.