Abstract
BACKGROUND: Awake spine surgery under spinal anesthesia may reduce perioperative risk in older or medically complex patients. This report presents the first documented case of an awake, single-position prone lateral transpsoas interbody fusion at L3-4 with simultaneous posterior decompression and fusion to treat a 77-year-old male with neurogenic claudication and mechanical back pain. A technical approach was developed to complete the procedure within the approximate 3-hour duration of spinal anesthesia. Prone positioning enabled simultaneous access to lateral and posterior corridors. Intraoperative navigation, dual-surgeon coordination, and patient-specific anesthetic planning were used to streamline the workflow. OBSERVATIONS: The procedure was completed within the spinal anesthesia window without the need for conversion to general anesthesia. The patient remained hemodynamically stable and tolerated prone positioning. No lumbar plexus-related complications occurred, and both clinical and radiographic outcomes were favorable. LESSONS: This case supports the feasibility of awake, single-position prone lateral lumbar interbody fusion with concurrent posterior decompression and fusion. It highlights key considerations for patient selection, anesthetic planning, and intraoperative coordination. Ongoing refinement of this technique may broaden its applicability in high-risk populations by balancing operative efficiency with the benefits of spinal anesthesia. https://thejns.org/doi/10.3171/CASE25467.