Total Intravenous Anesthesia vs Spinal Anesthesia in Patients Undergoing Unilateral Primary Total Knee Arthroplasty

Same-day discharge after total knee arthroplasty (TKA) has become a central goal within Enhanced Recovery After Surgery (ERAS) protocols, particularly in large academic centers. Spinal anesthesia is widely used in this setting and offers advantages through avoidance of general anesthesia-related risks, including airway instrumentation and systemic anesthetic exposure; however, spinal anesthesia may also be associated with prolonged motor blockade, urinary retention, and delayed mobilization, which can hinder same-day discharge in some patients. Rare risks include headache (sometimes called a spinal headache), back soreness, the numbness spreading too high, or the spinal not working well enough and needing conversion to general anesthesia. Very rare but serious risks include infection, bleeding around the spinal cord, or nerve injury.

Total intravenous anesthesia (TIVA) represents an alternative approach that avoids neuraxial anesthesia and its associated risks, including motor weakness and urinary retention, and may reduce postoperative nausea and vomiting. However, TIVA typically requires airway instrumentation and exposure to general anesthetic agents, which carry risks such as sore throat, airway-related discomfort, dental trauma, and potential concerns regarding anesthetic dosing and recovery, particularly in older adults. Processed EEG-guided anesthesia has been proposed as a strategy to optimize anesthetic depth during general anesthesia and potentially reduce overdosing, though its impact on recovery outcomes within contemporary ERAS pathways remains incompletely defined.

This research will address this knowledge gap through a prospective, randomized trial. By comparing same-day discharge rates as the primary outcome-and examining recovery efficiency, postoperative complications, cognitive outcomes, and patient satisfaction as secondary and exploratory measures-this study will provide foundational evidence to inform anesthetic selection. Ultimately, these findings have the potential to refine perioperative care, optimize recovery, and inform future definitive trials and clinical practice guidelines for TKA, improving outcomes for a growing elderly surgical population.

A study comparison of the two anesthesia techniques (TIVA vs spinal-block) in patients undergoing total knee arthroplasty (TKA) is appropriate because anesthetic choice directly influences perioperative recovery, same-day discharge rates, and patient-centered outcomes. Total Knee Arthroplasty (TKA) represents one of the most common and rapidly increasing elective procedures worldwide, particularly among the elderly population at higher risk for adverse outcomes and longer postoperative recovery. A prospective, randomized study design allows for a controlled comparison of the two widely utilized anesthetic techniques within the context of modern ERAS protocols, while also incorporating standardized follow-up to capture both short-term and 90-day long-term outcomes. Beyond individual patient recovery, this research carries broader public health implications: with an aging population and rising demand for TKA, optimizing perioperative pathways that enhance recovery, reduce complications, and support same-day discharge has the potential to decrease healthcare utilization, lower costs, and improve the sustainability of orthopedic care delivery.

Based on our experience caring of these patients over the years, patients with strong preferences or contradictions to one of the two approaches are relatively small (~10-15%). Most patients defer to their anesthesiologists and surgeons to provide the best care plan for them. In the current practice, both anesthesia approaches are widely acceptable care for most patients undergoing TKA and no clear advantages in risk/benefit ratio in same day discharge between methods of anesthesia.