The Influence of Remimazolam versus Propofol on Quality of Emergence and Sleep in Elderly Patients After Spinal Surgery: A Non-Randomized Observational Study.
Zhang J, Zhao B, et al. • Drug design, development and therapy • 2026
Among elderly patients undergoing elective posterior lumbar surgery, the combination of remimazolam and flumazenil was associated with shorter emergence and extubation times, as well as improved postoperative sleep quality compared to propofol.
Key Findings
Results
Remimazolam with flumazenil reversal was associated with significantly shorter emergence times compared to propofol in elderly patients undergoing spinal surgery.
Study enrolled patients aged 60-85 years with ASA classification I-III and preoperative PSQI score <7
Group R (remimazolam, n=79) and Group P (propofol, n=80) were allocated based on attending anesthesiologist preference in a non-randomized design
Emergence time difference was statistically significant (P<0.05)
Multivariable quantile regression confirmed remimazolam independently shortened emergence time (P<0.001)
Upon cessation of anesthetic infusion, Group R received flumazenil for reversal
Results
Extubation time was significantly shorter in the remimazolam group compared to the propofol group.
Extubation time was a secondary outcome measure
The difference was statistically significant (P<0.05)
Both emergence and extubation time improvements were observed in patients aged 60-85 undergoing posterior lumbar decompression with bone graft fusion and internal fixation
Results
Patients in the remimazolam group had significantly higher Richmond Agitation-Sedation Scale (RASS) and Aldrete scores at PACU admission and 15 minutes post-admission.
RASS and Aldrete scores were assessed at PACU admission and 15 minutes post-admission
Scores were significantly higher in the remimazolam group at both time points (P<0.05)
Multivariable analysis showed a significantly higher awake rate at PACU admission in the remimazolam group (P<0.001)
Higher RASS and Aldrete scores indicate better levels of consciousness and readiness for discharge from the PACU
Results
Remimazolam was independently associated with improved postoperative sleep quality on postoperative nights 1 through 3 compared to propofol.
Sleep quality was measured using the Richards-Campbell Sleep Questionnaire (RCSQ)
RCSQ scores were significantly better in the remimazolam group on PON 1-3 (P<0.001)
Preoperative sleep quality was controlled for by enrolling only patients with PSQI score <7 (indicating good preoperative sleep)
Methods
The study measured incidence of injection pain during induction and postoperative nausea, vomiting, and dizziness as secondary safety outcomes.
Incidence of injection pain during induction was recorded for both groups
Nausea, vomiting, and dizziness were assessed within 30 minutes postoperatively
Numeric Rating Scale (NRS) scores for rest pain were also recorded on postoperative nights 1-3
These outcomes were included as secondary endpoints to characterize the overall safety and comfort profile of each anesthetic
Methods
This was a prospective, non-randomized, single-center observational cohort study in which group allocation was determined by attending anesthesiologist preference.
Study design was a prospective cohort (non-randomized observational study)
Patients were aged 60-85 years with BMI ≤35 kg/m² and ASA I-III classification
All patients underwent posterior lumbar decompression with bone graft fusion and internal fixation under general anesthesia
Non-randomized design is an acknowledged limitation, as anesthesiologist preference introduced potential selection bias
Single-center design limits generalizability of findings
What This Means
This research suggests that in elderly patients (ages 60-85) having spinal surgery, using remimazolam—a newer sedative medication—along with a reversal drug called flumazenil to wake patients up afterward, may help patients recover from anesthesia more quickly than the commonly used drug propofol. Patients given remimazolam woke up faster, had their breathing tube removed sooner, and were more alert when they arrived in the recovery room compared to those who received propofol.
Beyond the immediate recovery room experience, this research also suggests that remimazolam may be linked to better sleep quality in the first three nights after surgery. Since poor sleep after surgery is a common and bothersome problem for elderly patients, this finding could be meaningful for their overall recovery experience. The study carefully screened out patients who already had poor sleep before surgery, so the differences seen were less likely to be explained by pre-existing sleep problems.
It is important to note that this was not a randomized controlled trial—patients were assigned to one drug or the other based on their doctor's preference rather than by chance—which means hidden differences between the groups could have influenced the results. The study also took place at a single hospital, so findings may not apply to all settings. Nonetheless, the results provide preliminary evidence that remimazolam combined with flumazenil reversal may offer advantages over propofol for elderly spinal surgery patients in terms of both speed of awakening and postoperative sleep quality.
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Zhang J, Zhao B, Liu B, Yang S, Wang J, Li Z, et al.. (2026). The Influence of Remimazolam versus Propofol on Quality of Emergence and Sleep in Elderly Patients After Spinal Surgery: A Non-Randomized Observational Study.. Drug design, development and therapy. https://doi.org/10.2147/DDDT.S593190