Daring discourse

Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101578 on 18 June 2020. Downloaded from http://rapm.bmj.com/ on June 22, 2020 at University of Rochester Medical Center.
Spinal versus general anesthesia for The Golden Rule from the King James Bi-
ble: ‘Do unto others as you would have
them do unto you’ (Matt. 7:12; see also
outpatient joint arthroplasty: can the Luke 6:31).

evidence keep up with the patients? SA is the preferred type for

1 2
Eric S Schwenk  ‍ ‍, Rebecca L Johnson  ‍ ‍
Abstract
Total joint arthroplasty (TJA) is transitioning
to be an outpatient rather than an inpatient
procedure under national and institutional
pressures to increase volumes while reducing
hospital costs and length of stay. Innovative
surgical and anesthesia techniques have
allowed for earlier ambulation and physical
therapy participation, maximizing the chance
that an appropriately selected patient may
be discharged within a day of surgery. The
choice of anesthesia type is a modifiable factor
that has a major impact on both surgical
outcomes and discharge readiness. Recent
large database studies have provided evidence
for improved outcomes, including decreased
mortality, with the use of spinal anesthesia.
the drive toward outpatient TJA.1 The
perioperative TJA experience, including
minimally invasive surgical and regional
anesthesia techniques and multimodal
analgesia, play important roles in this
paradigm. In addition, with the arrival
of COVID-19 and associated risks of
hospital-­acquired infection, efforts to
discharge appropriate patients on the day
of surgery rather than require a hospital
admission should be pursued. Same-­ day
TJA success stories to date have high-
lighted the importance of patient selection
and preparation and choosing the right
patients may be the most important factor
in meeting this goal.2 A recent review
outpatient TJA
Eric S Schwenk
When it comes to anesthesia for outpa-
tient TJA, the choice is clear: SA is the
best. Several studies with large numbers
of patients have addressed the topic of
anesthesia type and concluded that there
are outcome benefits to SA. As early as the
1980s, it was recognized that SA reduces
the amount of intraoperative fibrinolysis
during TJA.9 There is also evidence that
fewer patients undergoing TJA under SA
receive blood transfusions than those who
receive GA.10 This would clearly be bene-
ficial in patients scheduled for outpatient
TJA, in whom ongoing bleeding and trans-
fusion would make same-­ day discharge
unlikely. The decision to discharge a
patient on the day of surgery is a personal-
ized one that should factor in comorbidi-
ties as well as patient and physician desires

Protected by copyright.
concluded that common eligibility criteria and comfort level. Although some patient
However, few randomized, controlled trials
for outpatient TJA included a body mass populations, such as those who are vulner-
exist and database studies have limitations.
Modern general anesthesia techniques, index less than 40 kg/m2, living within able or frail, may have fewer complica-
including total intravenous anesthesia and 1 hour of the hospital, non-­ smoking tions with SA,11 these patients may not be
infusions targeted to anesthetic depth, may status, and the absence of diabetes, cardio- good outpatient TJA candidates for those
make some of these differences insignificant, vascular disease, and steroid use.3 Others very same reasons.
especially when newer regional anesthesia have excluded patients with opioid toler- Evidence suggests that one of the most
and local infiltration analgesia techniques ance, anemia and age greater than 75 years likely factors to impede same-­day discharge
are incorporated into TJA enhanced recovery as well.4 When relatively healthy patients after TJA is nausea and vomiting.4 When
protocols. Multimodal analgesia for all TJA are chosen, outpatient TJA appears to examining the contribution of anesthesia
patients may also help minimize differences have similar complication rates to inpa- to postoperative nausea and vomiting
in pain. Perhaps even more important than tient TJA.3 However, multiple aspects of (PONV), there is evidence that SA is supe-
anesthesia technique is the proper selection the perioperative care of these patients rior in reducing its incidence. In a retro-
of patients likely to meet the necessary have not been studied, including preop- spective analysis of 3922 patients who
milestones for early discharge. In this article, erative medications, optimization of underwent THA under GA or SA, GA was
we provide two contrasting viewpoints on the medical comorbidities, type of anesthesia, associated with more PONV.12 A meta-­
optimal primary anesthetic for outpatient TJA. fluid management, postoperative anal- analysis also found that SA reduced PONV
gesia and discharge criteria. The ‘ideal’ after THA when compared with GA.13
Introduction perioperative protocol for outpatient Modern outpatient TJA pathways are
Total joint arthroplasty (TJA) is transi- TJA remains unknown. Several retrospec- now frequently turning to intermediate-­
tioning at some centers to be an outpa- tive studies3 5 6 and a recent International acting local anesthetics to provide SA
tient procedure in appropriately selected Consensus Statement7 have compared that allows for early ambulation. Histor-
patients. The creation of bundled outcomes between general anesthesia (GA) ical concerns over transient neurological
payments and removal of total knee and spinal anesthesia (SA) for TJA, with symptoms (TNS)14 may no longer be
arthroplasty (TKA) from the inpatient-­ most concluding that SA reduces the rate relevant with improved formulations of
only list of procedures may have signif- of complications and healthcare resource local anesthetics and widespread use of
icant economic consequences helping utilization.6 8 None of these studies specif- non-­steroidal anti-­inflammatory drugs
for preemptive analgesia. There is recent
1
Anesthesiology, Sidney Kimmel Medical College at ically examined the subgroup of patients evidence that TKA patients who received
Thomas Jefferson University, Philadelphia, Pennsylvania, who would be eligible to be outpatient spinal mepivacaine ambulated sooner
USA TJA candidates. The purpose of this article than patients who receive spinal bupiva-
2
Anesthesiology and Perioperative Medicine, Mayo
is to provide two contrasting views on the caine,15 while prilocaine was associated
Clinic, Rochester, Minnesota, USA
preferred anesthesia type for outpatient with faster recovery after orthopedic and
Correspondence to Dr Eric S Schwenk, TJA, relying on the published evidence
Anesthesiology, Sidney Kimmel Medical College at
urological surgery compared with bupiva-
Thomas Jefferson University, Philadelphia, PA 19107, as much as possible, interspersed with the caine.16 In another study, spinal lidocaine
USA; E​ ric.​Schwenk@​jefferson.​edu opinions of the authors. enabled successful outpatient TJA with
Schwenk ES, Johnson RL. Reg Anesth Pain Med Month 2020 Vol 0 No 0    1
 Daring discourse

no reports of TNS.17 These results should
be confirmed in additional studies before
advocating for the use of spinal lidocaine
given its longstanding association with
TNS. The recovery profile of spinal mepi-
vacaine is favorable for outpatient TJA18
and future studies should focus on its use
in outpatient TJA.
Finally, multiple studies have found that
SA reduces major complications after TJA.
Perlas et al8 reported that both 30-­ day
mortality and length of stay were reduced
with SA and Memtsoudis et al6 reported
similar findings in a national administrative
database study of over 500 000 patients.
Because TJA is a surgery primarily for
older adults, a common concern among
patients is that of postoperative cogni-
tive dysfunction. A recent meta-­ analysis
addressed this topic and found that there
may be an increase in early postoperative
cognitive dysfunction when GA is used.19
It is clear, to me, that patients both feel
better and experience superior outcomes
when SA is used for TJA. When I show up
for my TKA in 25 years, please give me a
short-­acting spinal and an adductor canal
block along with local infiltration anal-
Advocates for SA often cite benefits
such as avoidance of endotracheal intuba-
tion, mechanical ventilation and reduced
exposure to neuromuscular blockade
medication as support to use SA over GA.
Although arguably a reliable neuraxial
technique, SA is not without failure,
with rates approaching 1%–17% in some
settings.20 Mechanisms of failure may
include unsuccessful lumbar puncture,
loss of injectate, incorrect drug baricity or
dose for a particular surgery and patient
anatomical abnormalities, among others.20
Notably, there are clear contraindications
to SA use related to patient refusal or use
of anticoagulants. The fixed duration of
action of SA, especially with short-­acting
agents that are likely to see increased use
for outpatient TJA, can be a drawback for
surgeons who are not as efficient. Other
potential issues, such as urinary reten-
tion7 and TNS,14 should be expected more
when SA is chosen.
The benefits of SA seen in prior studies
are compelling but more so for older adult
patients with multiple comorbidities.10 It
is also difficult to study the true benefit
of SA as patients often receive moderate
Reg Anesth Pain Med: first published as 10.1136/rapm-2020-101578 on 18 June 2020. Downloaded from http://rapm.bmj.com/ on June 22, 2020 at University of Rochester Medical Center.
motor weakness, interfere with PT read-
iness.4 The alternative and backup to SA
failure, which is GA, has been shown to
be better in these regards. Stambough et
al21 reported that over 96% of their rapid
recovery cohort featuring GA participated
in PT within 2 hours of surgery and were
discharged on postoperative day 1. In two
separate randomized controlled trials,
Harsten et al demonstrated faster ambula-
tion and better overall recovery with total
intravenous GA over SA after TJA.22 23
Additionally, GA patients were more likely
to desire the same type of anesthesia for
subsequent surgeries than SA patients.
These results are not surprizing to those
of us who hear frequent requests for GA
because of fears about ‘hearing things’
during surgery.
Unlike SA practice, which has been
fairly stable for many decades, the conduct
of GA has evolved significantly. Changes
toward newer pharmacological agents
(both intravenous and inhalational),
target-­controlled infusions, use of supra-
glottic devices and newer ventilation
equipment have made modern GA suit-

gesia. I have no doubt this combination
will do the trick.
GA is the preferred type for
outpatient TJA
Rebecca L Johnson
In the event I require TJA, please provide
me preemptive oral analgesia, aggressive
PONV prophylaxis, a modern targeted
total intravenous general anesthetic,
surgeon-­administered local infiltration
analgesia, and access to PT on the day of
my surgery.
or even deep sedation along with SA,
thereby clouding the picture. Even in
large cohorts, results are observed to be
only marginally better with SA selec-
tion. Patients who are offered ‘fast-­track’
surgery are carefully prescreened and
patients that may benefit the most from SA
excluded as candidates for outpatient TJA.
Furthermore, same-­day discharge success
is heavily linked to early physical therapy
(PT) participation.2 Residual spinal
effects, including spinal-­ induced hypo-
tension and dizziness and limb numbness/
Protected by copyright.
able for outpatient TJA. Although there
is emerging evidence on the use of short-­
acting local anesthetics, such as mepiva-
caine and prilocaine, variability with SA
blockade offset continues to limit wide-
spread use in same-­ day TJA.15 Further-
more, SA’s historical benefits in reducing
thromboembolic events, bleeding and
transfusion8 may no longer be relevant
with current prophylactic techniques. The
benefits of modern GA may not be fully
appreciated as the studies have yet to be
performed.

Table 1  Comparison of spinal anesthesia (SA) and general anesthesia (GA) for outpatient total joint arthroplasty
Evidence favors Evidence favors
Perioperative factor SA GA Comments
Perioperative mortality + Consensus based on existing evidence6; however, unknown advantage in
Pulmonary complications patients qualifying for outpatient TJA
Acute renal failure
Infections
Deep vein thrombosis Pulmonary embolism +/− SA may confer small benefit6 but may provide no difference in modern
practice5
Surgical bleeding +/− Limited evidence that SA reduces bleeding6 8 but anti†fibrinolytics may
Transfusion eliminate differences
Major adverse cardiac events – – No difference based on existing evidence8
Postoperative nausea and vomiting +/− SA may confer small benefit12 but may be no difference with modern total
intravenous anesthesia techniques and fluid replacement
Urinary retention + Lower odds with GA6
Early physical therapy participation + GA may be advantageous,22 23 especially compared with SA with
bupivacaine
Postoperative pain – – Early pain may be higher with GA but after 6 hours SA results in more
pain22 23; multimodal analgesia may minimize differences
+ Likely benefit; +/− Possible benefit; − No difference.
TJA, total joint arthroplasty.

2 Schwenk ES, Johnson RL. Reg Anesth Pain Med Month 2020 Vol 0 No 0


Lastly, questions on how multimodal
analgesia, peripheral nerve blockade and
local infiltration analgesia techniques
alone or together impact anesthesia
outcomes and anesthetic choice have yet
to be answered. Regardless of primary
anesthesia type, patients randomized to
receive multimodal analgesia along with
ropivacaine-­ based local infiltration anal-
gesia have comparable pain control to
traditional peripheral nerve block cath-
eter techniques after both TKA and THA.
Recently, the combination of adductor
canal and infiltration between popliteal
artery and capsule of knee blocks with
local infiltration analgesia has effectively
managed pain after TKA.24 However,
conflicting reports have emerged showing
similar discharge outcomes in TKA
patients who received local infiltration
analgesia whether patients receive addi-
tional peripheral nerve blockade or not.25
Although the ideal intraoperative anes-
thetic for outpatient TJA remains a topic
of debate, GA provides for earlier and
more reliable participation in PT and, in
combination with local infiltration anal-
gesia, maximizes the chance of same-­day
discharge better than SA. A comparison of
outcomes related to anesthetic technique
is shown in table 1.
Conclusions
Despite convincing arguments on both
sides about GA vs SA for outpatient TJA,
randomized, controlled trials comparing
the two types of anesthesia in the modern
era, either in the outpatient population
or the entire TJA population, are sparse.
Although the reasons for this are not
entirely clear, the logistics of conducting
such a study and the numbers required
to show a difference in morbidity and
mortality make this a challenging task.
Individual institutions each have prefer-
ences and biases for either GA or SA, which
introduces ethical and enrollment chal-
lenges. Future studies, whether random-
ized, controlled trials or national database
studies, should focus on the variables in
perioperative care that affect discharge
time, including the type of anesthesia.
Modern GA techniques and short-­acting
local anesthetics should be incorporated
into future studies. Patients who are
predetermined to be suitable outpatient
TJA candidates should be included in
these studies to minimize the effect of
institutional preferences and biases. As
the evidence stands today, both GA and
SA can facilitate same-­ day discharge if
fast-­
track pathways that incorporate
Schwenk ES, Johnson RL. Reg Anesth Pain Med Month 2020 Vol 0 No 0
multimodal analgesia are used but one
technique may work better at each insti-
tution based on preferences, resources and
skills available. At this time, patient selec-
tion may be the most important factor in
achieving successful outpatient outcomes.
We look forward to the publication of
studies comparing anesthetic techniques
that are specific to this population.
Twitter Eric S Schwenk @ESchwenkMD and Rebecca L
Johnson @rljohnsonmd
10 Pugely AJ, Martin CT, Gao Y, et al. Differences in
Contributors  Both authors contributed equally in
manuscript preparation.
Funding  The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned;
externally peer reviewed.
© American Society of Regional Anesthesia & Pain
Medicine 2020. No commercial re-­use. See rights and
permissions. Published by BMJ.
To cite Schwenk ES, Johnson RL. Reg Anesth Pain Med
Epub ahead of print: [please include Day Month Year].
doi:10.1136/rapm-2020-101578
Received 17 April 2020
Revised 20 May 2020
Accepted 22 May 2020
Reg Anesth Pain Med 2020;0:1–3.
doi:10.1136/rapm-2020-101578
ORCID iDs
Eric S Schwenk http://​orcid.​org/​0000-​0003-​3464-​4149
Rebecca L Johnson http://​orcid.​org/​0000-​0002-​1920-​
9774
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