Comment on Attari et al: Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: randomized clinical trial

Dear Editor,We would like to commend Attari et al on their excellent study entitled ‘Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: A randomized clinical trial’.1 The authors’ findings are consistent with those of Jellish et al2 and Rung et al3 who recommend spinal anaesthesia over general anaesthesia for operative procedures on the lumbar spine lasting less than two hours. However, we would like to discuss an important aspect of this study, namely deterioration in neurological status after administration of spinal anesthesia. Hebl et al reported a higher incidence of post-operative neurological complications after central neuraxial blockade in patients with underlying spinal canal pathology. However, in absence of a control group, the authors could not determine whether such complications were because of the anesthetic technique, surgical procedure or natural history of the disease.4 It has been proposed that spinal anesthesia may increase the intra-canal pressure in patients with lumbar canal stenosis and result in ischaemic damage to the spinal cord or nerve roots.5 The authors were careful to exclude patients with severe lumbar canal stenosis and arachnoiditis and none of the patients had arachnoid cysts or ankylosing spondylitis. This could probably account for the fact that no patient had post-operative worsening of neurological status. In view of these findings, we would like to emphasize the need for proper patient selection in order to minimise neurological complications. Also, there is need for a multicenter collaborative study to evaluate whether or not neurological complications in patients with pre-existing spinal pathologies could be attributed to spinal anaesthesia before this modality can be declared as a safe alternative to general anaesthesia.