{
  "abstract": "Spinal anesthesia (SA) has long been a mainstay in anesthetic practice, primarily for inpatient procedures and now is becoming more common in the ambulatory setting, particularly for select procedures and patient populations. Recent literature highlights increased interest and utilization of SA for outpatient surgeries, including orthopedic, anorectal, and minimally invasive spine procedures, as well as in pediatric populations. Advances in short-acting local anesthetics have addressed prior concerns about delayed recovery and urinary retention, making SA more adaptable to ambulatory workflows. 1–3Compared to general anesthesia (GA), SA is associated with reduced postoperative pain, nausea, and opioid consumption, while facilitating same-day discharge and maintaining a low complication rate. Despite these benefits, SA remains underutilized due to lingering concerns over duration and flexibility. Nevertheless, growing clinical evidence is driving a trend toward broader adoption in ambulatory settings, confirming its safety, efficacy, and operational feasibility.This article explores the evolving role of SA in ambulatory surgery, examining patient selection, pharmacological advances, clinical benefits, and implementation strategies for safe and effective practice.Introduction The paradigm shift towards outpatient surgery is driven by patient demand, hospital efficiency goals, and healthcare cost containment. In this context, anesthetic techniques that promote rapid recovery, minimal side effects, and patient satisfaction are essential. While GA remains widely used, SA offers a valuable alternative, particularly for procedures below the umbilicus. The development of short-acting spinal agents has revitalized interest in this technique for ambulatory care. 4 Materials and Methods A systematic search was performed in PubMed, Scopus, Embase, UpToDate, and the Cochrane Library, following PRISMA-ScR guidelines. We included systematic reviews, meta-analyses, and controlled clinical trials without restrictions on publication type or language. A preliminary screening of titles and abstracts was conducted, followed by full-text evaluation to identify eligible studies. MeSH terms used included ‘spinal anesthesia,’ ‘ambulatory surgical procedures,’ ‘short-acting local anesthetics,’ and ‘complications of spinal anesthesia.’Indications and Surgical ProceduresSA is particularly suitable for short to intermediate-duration surgeries. involving the lower abdomen, pelvis, and lower extremities.Traditionally, orthopedic patients who have benefited from SA are those undergoing procedures such as knee arthroscopy, anterior cruciate ligament repair, and foot and ankle surgeries. However, in recent years, reports have emerged on the use of SA for total joint arthroplasty in ambulatory settings. In this group, SA is associated with high rates of same-day discharge and reduced postoperative pain and nausea.5 Additionally, minimally invasive spine surgeries are increasingly performed under spinal anesthesia to facilitate early mobilization and discharge.6 Some urologic procedures (such as transurethral resections and varicocelectomy), gynecologic procedures, and abdominal surgeries (including inguinal hernia repair, hemorrhoidectomy, and anal fistula repair) are also commonly performed under spinal anesthesia in the ambulatory setting. These procedures are well suited for SA due to their short duration and the possibility of using short-acting agents to enable rapid recovery.7 Careful patient selection is critical to the success of SA in the ambulatory setting. Ideal candidates include: ASA I–II patients, Body Mass Index (BMI) < 35 kg/m2. Low risk for obstructive sleep apnea or cardiovascular instabilityNo history of chronic urinary retention or neurologic disorder and Anticipated surgery duration < 90 minutesPatient counseling is vital to align expectations regarding the anesthetic plan, recovery, and discharge criteria.Pharmacology and Drug SelectionThe choice of local anesthetic determines the duration and quality of spinal blockade. Short-acting and intermediate-acting agents are preferred for ambulatory SA due to their favorable pharmacokinetic profiles—fast onset, predictable offset, and low incidence of transient neurologic symptoms (TNS).8 9 Local anesthetics commonly used for SA in the ambulatory setting are:2-Chloroprocaine is favored for its rapid onset, short duration, and excellent recovery profile, making it particularly suitable for short-duration ambulatory procedures. It consistently demonstrates the fastest times to discharge, ambulation, and spontaneous voiding. The incidence of transient neurologic symptoms (TNS) is very low, especially with preservative-free formulations. Although rare cases of incomplete cauda equina syndrome have been reported, they are exceedingly uncommon with modern preservative-free preparations. Urinary retention is infrequent and comparable to other short-acting agents.8 11 Prilocaine is also widely used, offering a slightly longer duration than 2-chloroprocaine but still supporting timely discharge and low TNS risk. It is suitable for procedures of intermediate duration.Lidocaine is effective for spinal anesthesia in ambulatory settings, but is associated with a higher risk of TNS, especially in lithotomy position, which has led to a decline in its use in favor of alternatives with better safety profiles.10 Rates historically have been reported up to 20%,12 though recent data in the context of multimodal analgesia suggest a much lower incidence (<1%).10 Other side effects include hypotension, headache, backache, and, rarely, allergic reactions. Permanent neurologic injury is extremely rare.Mepivacaine provides a reliable block for procedures of moderate duration but may occasionally prolong recovery. The main side effect is TNS, with an incidence generally lower than lidocaine but still present (reported between 1.7% and 6.4%).12 Other side effects include hypotension, headache, and urinary retention, but these are not more frequent than with other short-acting agents. Permanent neurologic injury is rareLow-dose bupivacaine: The risk of TNS is very low. The main side effects are dose-dependent hypotension and urinary retention, but these are less frequent with low-dose regimens. Prolonged motor and sensory block can occur if higher doses are used, but this is minimized with ambulatory-appropriate dosingIn summary, 2-chloroprocaine is the agent of choice for most short-duration ambulatory spinal anesthetics, with prilocaine, lidocaine, and mepivacaine as additional options depending on procedure length and patient factors.Abstract FT14 Table 1Comparative table of commonly used local anesthetics for spinal anesthesia in ambulatory settingComparison Of Spinal Anesthesia And General Anesthesia In Ambulatory SurgeryMultiple studies and meta-analyses have compared SA and GA in the outpatient setting. SA offers several distinct advantages. While GA allows faster operating room turnover and may be preferred for upper body procedures, SA is often associated with better postoperative analgesia and fewer opioid-related side effects. The choice should be tailored based on patient characteristics, surgical site, and institutional protocols.8 13 A multicenter observational study by Capdevila et al. (2020)7 analyzed factors influencing anesthetic choice in ambulatory settings. The study found that SA was more frequently selected for lower limb and urologic procedures, older patients, and when enhanced postoperative analgesia was prioritized. GA was preferred for shorter procedures and when rapid turnover was a concern. Institutional experience and anesthesiologist preference also played significant rolesAbstract FT14 Table 2Comparing spinal anesthesia and general anesthesiaAdvantages Of Spinal Anesthesia In The Ambulatory SettingSA presents several benefits over general anesthesia, particularly in fast-track surgical environments:Superior postoperative analgesia, reducing reliance on systemic opioidsDecreased incidence of postoperative nausea and vomiting (PONV)Minimal airway manipulation, reducing the risk of sore throat and respiratory complicationsFaster cognitive recovery compared to general anesthesiaCost savings through reduced PACU time and resource utilization2 13 A study by Camponovo et al.3 demonstrated that SA with chloroprocaine significantly reduced time to discharge readiness compared to GA for knee arthroscopy. Similar results were reported in a recent cohort by Tasso et al,14 where patients undergoing knee arthroscopy under chloroprocaine spinal anesthesia achieved early ambulation and same-day discharge with minimal complications.Challenges And Limitations Of Spinal Anesthesia In The Ambulatory SettingDespite its advantages, there are several limitationsUrinary retention: Although rare with low-dose short-acting agents, it remains a concern. Strategies include limiting block height, avoiding fluid overload, and promoting early mobilization.13 Delayed ambulation: Motor recovery time must be closely monitored. Using low-dose and short-acting agents supports quicker ambulation.Post-dural puncture headache: Incidence is low with modern pencil-point needles (25G or 27G).2 Block failure or insufficient level: Proper technique and anatomical familiarity are essential. Always prepare for conversion to general anesthesia if needed.Monitoring and Discharge CriteriaOutpatient spinal anesthesia requires well-defined monitoring protocols and discharge criteria. Patients should:Achieve full motor recovery (modified Bromage score 0)Be able to ambulate with minimal assistanceHave stable vital signs and pain controlTolerate oral fluidsUrinate spontaneously or be at low risk for urinary retention (voiding is not mandatory in all protocols)2 13 Evidence and Meta-Analyses A 2016 Cochrane meta-analysis by Guay et al 1 compared SA versus GA in hip fracture repair and found no significant difference in unplanned hospital admissions, postoperative complications, or mortality rates. Importantly, SA was associated with reduced risk of deep vein thrombosis and improved analgesia in some subgroups.A more recent and comprehensive Bayesian network meta-analysis by Singh et al.8 (2025) evaluated 48 randomized controlled trials involving ambulatory non-arthroplasty surgery. The study concluded that chloroprocaine and prilocaine offered the best balance of rapid recovery, low urinary retention, and minimal transient neurologic symptoms. Specifically, chloroprocaine ranked highest in terms of early ambulation and readiness for discharge, whereas prilocaine provided a slightly longer analgesic window with acceptable safety. These findings reinforce the preferential use of these agents in outpatient SA.Clinical studies have confirmed the safety and effectiveness of intrathecal chloroprocaine for outpatient orthopedic procedures. For example, in a prospective cohort by Tasso et al, patients undergoing knee arthroscopy achieved early ambulation and same-day discharge, with excellent recovery profiles and high levels of patient satisfaction.Conclusion Spinal anesthesia, when tailored appropriately, is a safe, effective, and patient-friendly technique for ambulatory surgery. With careful selection, optimized pharmacology, and standardized protocols, it can enhance surgical efficiency and improve patient outcomes. As outpatient procedures continue to rise, spinal anesthesia will play an increasingly pivotal role in modern anesthetic practice.References Guay J, Nishimori M, Kopp SL. Spinal versus general anaesthesia for hip fracture repair in adults. Cochrane Database Syst Rev. 2016;2(2):CD001159.Bader AM, Datta S. Spinal anesthesia for outpatient surgery. Anesth Analg. 1992;74(4):394–398.Camponovo C, Wulf H, Ghisi D, Fanelli A. Intrathecal chloroprocaine: a review of the clinical literature. Reg Anesth Pain Med. 2010;35(6):556–564.Stewart J, Gasanova I, Joshi GP. Spinal anesthesia for ambulatory surgery: current controversies and concerns. Curr Opin Anaesthesiol. 2020 Dec;33(6):746–752.Calkins TE, Johnson EP, Eason RR, Mihalko WM, Ford MC. Spinal versus general anesthesia for outpatient total hip and knee arthroplasty in the ambulatory surgery center: a matched-cohort study. J Arthroplasty. 2024 Jun;39(6):1463–1467.Garg B, Ahuja K, Sharan AD. Regional anesthesia for spine surgery. J Am Acad Orthop Surg. 2022 Sep 1;30(17):809–819.Capdevila X, Aveline C, Delaunay L, Bouaziz H, Zetlaoui P, Choquet O, Jouffroy L, Herman-Demars H, Bonnet F. Factors determining the choice of spinal versus general anesthesia in patients undergoing ambulatory surgery: results of a multicenter observational study. Adv Ther. 2020 Jan;37(1):527–540.Singh NP, Siddiqui NT, Makkar JK, Guffey R, Singh PM. Optimal local anesthetic for spinal anesthesia in patients undergoing ambulatory non-arthroplasty surgery: a systematic review and Bayesian network meta-analysis of randomized controlled trials. Can J Anaesth. 2025 Apr;72(4):550–566.Wulf H, Hampl K, Steinfeldt T. Speed spinal anesthesia revisited: new drugs and their clinical effects. Curr Opin Anaesthesiol. 2013 Oct;26(5):613–20.Amaral S, Chen E, Kumar AH, MacLeod DB, Bullock WM, Ray N, Manning E, Martinez-Wilson H, Dooley J, Ohlendorf B, Gadsden J. Incidence of transient neurologic symptoms in patients receiving lidocaine spinal anesthesia for outpatient joint arthroplasty. Reg Anesth Pain Med. 2025 Apr 29;rapm-2025–106541.Goldblum E, Atchabahian A. The use of 2-chloroprocaine for spinal anaesthesia. Acta Anaesthesiol Scand. 2013 May;57(5):545–52.YaDeau JT, Liguori GA, Zayas VM. The incidence of transient neurologic symptoms after spinal anesthesia with mepivacaine. Anesth Analg. 2005 Sep;101(3):661–665.Schubert AK, Wiesmann T, Wulf H, Dinges HC. Spinal anesthesia in ambulatory surgery. Best Pract Res Clin Anaesthesiol. 2023;37(2):109–12Tasso F, Monteleone G, Biamino C, et al. Use of chloroprocaine in orthopedic day surgery: a brief report in a cohort of patients undergoing knee arthroscopy. Eur Rev Med Pharmacol Sci. 2023;27(23):11566–11573.",
  "authors": [
    {
      "affiliations": [
        "Anesthesia. Pain Unit, Hospital Universitario de Getafe, Madrid, Spain"
      ],
      "name": "Esperanza Ortigosa"
    }
  ],
  "title": "FT14 Spinal anesthesia in the ambulatory setting",
  "uid": "3307418b-f63c-5a29-9999-98b41d3dd32a"
}