The Influence of Remimazolam versus Propofol on Quality of Emergence and Sleep in Elderly Patients After Spinal Surgery: A Non-Randomized Observational Study

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Purpose: Elderly patients undergoing spinal surgery face postoperative challenges, including delayed emergence and sleep disorders. The study aims to compare remimazolam versus propofol on postoperative emergence and sleep quality in this population, providing evidence for perioperative anesthesia management. Patients and methods: This prospective cohort study enrolled patients age 60– 85 years; American society of anesthesiologists(ASA) I–III;preoperative Pittsburgh Sleep Quality Index (PSQI)score < 7; Body Mass Index(BMI) ≤ 35 kg/m 2 ;scheduled for posterior lumbar decompression with bone graft fusion and internal fixation under general anesthesia. Patients were allocated to remimazolam group (Group R, n=79) or propofol group (Group P, n=80) based on attending anesthesiologist preference. Anesthesia was induced and maintained with remimazolam in Group R and propofol in Group P. Upon cessation of anesthetic infusion, Group R received flumazenil for reversal. The primary outcome was emergence time. Secondary outcomes included extubation time;Richmond Agitation-Sedation Scale (RASS) and Aldrete scores in the Post-Anesthesia Care Unit(PACU); incidence of injection pain during induction; incidence of nausea, vomiting, and dizziness within 30 minutes postoperatively; Richards-Campbell Sleep Questionnaire (RCSQ) scores and Numeric Rating Scale (NRS) scores for rest pain on postoperative night(PON) 1– 3. Results: The R group had significantly shorter emergence and extubation times ( P < 0.05). Multivariable quantile regression confirmed remimazolam independently shortened emergence time ( P < 0.001). RASS and Aldrete scores were significantly higher in the R group at PACU admission and 15 min post-admission, with multivariable analysis showing a significantly higher awake rate at PACU admission ( P < 0.001). RCSQ scores were significantly better on PON 1– 3 ( P < 0.001), and multivariable analysis showed remimazolam independently associated with improved postoperative sleep quality. Conclusion: Among elderly patients undergoing elective posterior lumbar surgery with preoperative PSQI < 7, results from this single‑center study suggest that the combination of remimazolam and flumazenil is associated with shorter emergence and extubation times, as well as improved postoperative sleep quality. Keywords: remimazolam, geriatric, emergence, sleep effucuency, postoperative

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