Awake Anesthesia in Endoscopic and Minimally Invasive Transforaminal Lumbar Interbody Fusion (TLIF): A Systematic Review With Meta-analysis of Minimally Invasive TLIF (Spinal Versus General Anesthesia)

Objective: Transforaminal lumbar interbody fusion (TLIF) is commonly performed in patients with lumbar stenosis and segmental instability. Endoscopic and minimally invasive (MIS) TLIF have recently attracted increasing interest as less invasive surgical approaches. Although general anesthesia (GA) remains the standard anesthetic strategy, awake protocols, including spinal anesthesia (SA) and monitored anesthesia care (MAC), may offer potential advantages by reducing anesthetic risk. This review assessed the current literature on awake protocols, including SA and MAC, in patients undergoing endoscopic and MIS TLIF, with a focus on perioperative and clinical outcomes.Methods: A systematic database search of PubMed, Embase, Web of Science, and CINAHL was performed from inception to 25 August 2025 in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A proportional meta-analysis using a random-effects model was performed for perioperative outcomes, and funnel plots were used to assess potential publication bias. Study quality was evaluated using the MINORS (Methodological Index for Non-Randomized Studies) criteria.Results: Eleven studies involving 351 patients were included, with a mean follow-up of 19 months. In the meta-analysis, MIS TLIF performed under SA showed a trend towards improved perioperative outcomes, including length of stay, estimated blood loss, and operative time, compared with GA. However, the results were inconsistent and were not consistently statistically significant, and substantial heterogeneity limited interpretation. The analysis of endoscopic TLIF performed under MAC was limited to descriptive synthesis because of the lack of comparative datasets and heterogeneity in outcome reporting, precluding formal comparative inference between MAC and GA. No major complications were reported.Conclusion: MIS TLIF performed under SA or GA demonstrated comparable perioperative and clinical outcomes, with observed differences representing nonsignificant trends in predominantly low-level retrospective evidence. Endoscopic TLIF performed under MAC remains supported only by limited descriptive evidence, precluding quantitative synthesis. Overall, the current evidence is exploratory and hypothesis-generating. Higher-quality prospective comparative studies with standardized outcome reporting are needed to clarify the optimal anesthetic strategy for each distinct surgical approach.