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Tong Wu, Da Liu, Fanhe Meng, Jing-han Lu, Yi-feng Chen, Zheng Fan Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People’s Republic of ChinaCorrespondence: Da Liu, Department of Orthopedics, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, 110004, People’s Republic of China, Tel +86 18940257508, Email spinecmu@163.comPurpose: Here, we introduce a novel strategy of awake unilateral biportal endoscopic (UBE) decompression, which applies conscious sedation combined with stepwise local anesthesia (LA) as an alternative to general anesthesia (GA). The study aims to evaluate the feasibility of awake UBE decompression for degenerative lumbar spinal stenosis (DLSS) in elderly patients.Patients and Methods: This retrospective study included 31 consecutive patients who received awake UBE decompression for DLSS in our institution from January 2021 to March 2022. Clinical results were evaluated using patient-reported outcomes measures (PROM) including visual analog scale for leg pain (VAS-LP), Oswestry Disability Index (ODI), and modified MacNab criteria. The anesthesia effectiveness and intraoperative experience were evaluated by intraoperative VAS and satisfaction rating system.Results: UBE decompression was successfully performed in all patients under LA combined with conscious sedation. 26 (83.9%) patients rated the intraoperative experience as satisfactory (excellent or good) and 5 (16.1%) as fair. The mean intraoperative VAS was 3.41± 1.26. The VAS and ODI at each follow-up stage after surgery were significantly improved compared to preoperative scores (p < 0.01). At the last follow-up, 28 patients (90.3%) classified the surgical outcome as good or excellent, and 3 (9.7%) as fair. There were no serious complications or adverse reactions observed in the study.Conclusion: Our preliminary results suggest that awake UBE decompression is a feasible and promising alternative for elderly patients with DLSS.Keywords: awake spinal surgery, local anesthesia, degenerative lumbar disease, biportal endoscopic spine surgery, enhanced recovery after surgery