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tively. However, there is wide inter-patient variability in the response to opioids and significant side effects are associated with their use. We present the case of a 65-year-old man undergoing a twolevel lumbosacral posterior spinal fusion under general anesthesia using dexmedetomidine, lidocaine, and nitrous oxide, without the use of any intraoperative opioids and minimal opioids postoperatively for 24 h. To our knowledge, this is the first report documenting this anesthetic technique and its benefits through the first postoperative day. This technique has significant potential advantages over more traditional methods of general anesthesia involving opioids. A 65-year-old man with a history of hypertension, obesity, congenital bicuspid aortic valve status post-aortic valve replacement, pacemaker for postoperative bradycardia, and lumbar spinal stenosis presented for L4-S1 posterior lumbar fusion. His preoperative medications included aspirin 81 mg daily, metoprolol extended-release 50 mg daily, and lisinopril 5 mg daily. His surgical history included a previous L4-S1 laminectomy, appendectomy, arthroscopic knee surgery, and a bioprosthetic aortic valve replacement. General anesthesia was induced using dexmedetomidine (1 μg/kg over 10 min, started 10 min pre-induction), lidocaine (1.5 mg/kg), propofol (2 mg/kg), and succinylcholine (1 mg/kg). Following tracheal intubation, general anesthesia was maintained with intravenous infusions of dexmedetomidine (1 μg/kg/h), lidocaine (1.5 mg/kg/h), and inhaled nitrous oxide:oxygen (70 : 30). Intraoperatively, the patient required a phenylephrine infusion for the majority of the procedure (range, 10–25 μg/min); this was discontinued 5 min before extubation. The patient’s intraoperative heart rate did not vary significantly from his baseline heart rate. He was not pacemaker-dependent and the lower heart rate limit for active pacing was set at 50 beats/min. The dexmedetomidine infusion was discontinued approximately 30 min before the completion of surgery. The lidocaine infusion was discontinued immediately after extubation. The patient was extubated after a total operating time of 7.5 h without any complications. The patient did not receive any opioids intraoperatively. Within 3 min of extubation, the patient was awake and alert with an intact neurological exam. The patient denied experiencing pain in the operating room and on arrival at the postanesthesia care unit (PACU). The patient used a total of 0.4 mg of hydromorphone during his 90-min PACU stay via patientcontrolled analgesia. He was transitioned to oral morphine within 3 h of being discharged from the PACU and his total 24-h postoperative oral (PO) morphine milligram equivalent (MME) usage was 70 mg (IV MME 23.3 mg). His maximum pain score on a numeric rating scale (NRS) was 3/10. He denied nausea, vomiting, sedation, or constipation. Furthermore, he did not show any signs of respiratory depression (oxygen saturation, 97–100% on room air) postoperatively. The most common causes of delayed discharge from the Letter to the Editor

Opioid-free anesthesia using continuous dexmedetomidine and lidocaine infusions in spine surgery