Awake C1–2 laminectomy, instrumentation, and fusion: case report

Surgery of the cervical spine under conscious sedation has been rarely reported in the literature. The main indications are the lack of neurophysiological monitoring and surgery in patients with high cardiovascular risk. To date, no reports of awake C1-2 instrumentation have been published in the English-language literature. The authors present the case of a 76-year-old patient with multiple myeloma and severe cardiomyopathy associated with primary amyloidosis who experienced severe myelopathy from a C2 pseudotumor associated with an odontoid fracture. Due to his high cardiovascular risk, the patient underwent C1 decompression and C1-2 instrumentation and fusion via an awake technique. To accomplish this task, the authors performed multilayered muscular infiltration of local anesthetics and avoided manipulating the C2 root by anchoring C1 with a rod-claw system. The procedure did not last longer than that of general anesthetic approaches, and no complaints were reported by the patient during surgery, which he described as an overall "good experience." The patient was discharged on the 7th postoperative day and resumed his previous work 3 months later. Performing surgery under local anesthesia and conscious sedation reduces the risk of perioperative cardiovascular and respiratory complications in these high-risk patients by avoiding the use of drugs with cardiodepressant effects and endotracheal intubation.