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BackTable / MSK / Article
Awake Spine Surgery: Advantages & Applications
Taylor Spurgeon-Hess • Nov 1, 2023 • 32 hits
Awake spine surgery utilizing local and regional anesthesia, is advancing low back surgery, offering accelerated pain relief, reduced recovery timelines, and minimizing hospital stays. A large variety of spinal fusion techniques can now occur with spinal anesthesia, both locally and globally. This expanding scope, coupled with broadening patient selection criteria, has resulted in its adoption across diverse age and health brackets. As the awake spine surgery methodology becomes more prevalent, a notable shift in patient and staff perspectives has emerged, underlined by the tangible postoperative benefits and increased receptiveness from patients. Orthopedic spine surgeon, Dr. Alok Sharan, shares his experiences and tips surrounding the application of awake spine surgery.
This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• The transition from general to regional anesthesia for spine surgery offers faster patient mobilization and reduced recovery times.
• The utilization of awake spinal fusion leads to decreased procedure time and reduced narcotics use post-surgery, according to Dr. Sharan. The significant reduction in postoperative narcotic use among patients undergoing awake spinal surgery offers a compelling opioid-reducing alternative for patients and healthcare providers alike.
• In resource-constrained regions like India, awake procedures negate the need for general anesthesia machinery.
• The scope of awake spinal surgery has broadened, now including patients of varying ages and health conditions, underscoring the evolution and adaptability of these procedures. Patients with comorbidities, such as COPD, may benefit from awake spinal surgery as it allows them to avoid the risks associated with general anesthesia.
• Increasing patient preference for awake procedures is fueled by clear postoperative advantages.
• Dr. Sharan effectively employs the term "twilight" to mitigate patients’ fears and misconceptions about awake surgery, thereby enhancing their openness to and acceptance of the procedure.
Table of Contents
(1) The Shift Towards Awake Spine Surgery
(2) Practical Applications of Awake Spine Surgery
(3) Patient Selection Considerations for Awake Spine Procedures
The Shift Towards Awake Spine Surgery
Awake spine surgery represents a significant shift in low back surgical procedures. Instead of resorting to general anesthesia, surgeons use local and regional anesthesia, focusing specifically on the surgical area. Notable advantages include quicker patient mobilization, accelerated pain relief, and remarkably reduced recovery times. Traditional spinal fusion surgeries often leave patients hospitalized for several days and on narcotics for weeks. With awake spinal fusion, not only has the procedure time decreased, but patients also only spend a few hours in the hospital and only require narcotics for about four days. Dr. Sharan's transition to this method was motivated by alarming findings on the repercussions of general anesthesia in orthopedic surgeries, such as delirium. The potential of awake spine surgery became evident after Dr. Sharan’s successful execution, and since then, there has been an increase in both the application and utilization of awake procedures.
[Dr. Alok Sharan]
At a very high level, awake spine surgery is using local and regional anesthesia to perform low back surgery, not neck surgery, but low back surgery. In my mind, what awake spine surgery represents is just the notion of not using general anesthesia and being able to really just precisely numb up the area that needs surgery, that area in particular. Then along with it, the whole notion of awake spine surgery is that by avoiding general anesthesia, by using just local and regional anesthesia, we're able to mobilize patients quicker and get them out of pain quicker so that their recovery is fast. We'll get into the details later, but at this point now, a spinal fusion surgery, which normally results in patients staying in the hospital for about two, three days, and they're on narcotics for four to six weeks. At this point now, when we do an awake spinal fusion, it takes us about an hour, hour and a half to do, and patients stay in the hospital for four hours, they go home the same day, and they're on narcotics for only about four days.
[Dr. Jacob Fleming]
Wow.
[Dr. Alok Sharan]
The notion of awake spinal fusion at a high level is using local and regional anesthesia to do the surgery. The truth be told is, it's really just a protocol that allows patients to recover faster, mobilize quickly, and get out of pain quickly.
[Dr. Jacob Fleming]
Very nice. This reminds me of when I was in med school in intern year, rotating on the general surgery services, a lot of the so-called ERAS protocols, early return after surgery. This is a very similar concept. I also relate to this a lot because in the IR world, a vast majority of our patients we're intervening on will use either moderate sedation or local anesthesia. Of course, most of our procedures are pretty minorly disruptive of the tissue.
I'm really fascinated by this because it's using those similar kind of concepts to do something which is quite a bit more complex, which is a lumbar inner-body fusion. That's pretty amazing. Let's hear a little bit about your current practice and what was the impetus to begin offering awake spine surgery? How'd you go about it? Were there any individuals or specific practices that were an inspiration for you?
[Dr. Alok Sharan]
Great question. The truth is that it was really a confluence of events that came together. About 10 years ago, I was involved in a great research study where we were looking at the effects of general anesthesia on individuals who are older than 65 undergoing orthopedic surgery, hip replacement, knee replacement, spine surgery, and it was quite alarming. Just didn't really appreciate this, but the patients who had undergone general anesthesia after orthopedic surgery had developed a higher rate of delirium as opposed to individuals who had, let's say, spinal anesthesia.
That was alarming for me because delirium, as you know, is a significant problem. At a personal level, I felt it because my father had undergone heart surgery around the time. I saw intimately what happens when you develop delirium. I thought that was concerning because as we're trying to mobilize patients quicker, get them, let's say, perhaps out of the hospital quicker, what was alarming was that patients who are undergoing general anesthesia were developing delirium.
It increased significantly at post-op day one, which meant that we were basically doing surgery on individuals, discharging them home perhaps the same day, and not realizing that we're sending them home with the chance of them having delirium. Of course, there are tremendous collateral damages that can develop when you have delirium. It was around that time that my anesthesiologist and I, who I worked with closely, said, "You know what, maybe we should start doing more spine surgery without general anesthesia."
It's been described before, but it was also fortuitous that around that time, there was a very prominent individual in our hospital who needed spine surgery and had specifically asked for his spine surgery to be done without general anesthesia. We did, and everything worked out fine. It was beautiful, and I realized at that point, that you could do spine surgery without general anesthesia and the patients can do perfectly fine.
[Dr. Jacob Fleming]
It's really exciting to hear about. I mean, it seems like often these things we get so ingrained in our protocol and way of doing things. Spine surgery is, in a lot of people's mind, kind of this big, serious operation. Obviously, that goes with general anesthesia, then a single event of saying, "Okay, let's try this differently and see how it goes," can really start to change the paradigm.
[Dr. Alok Sharan]
Absolutely. I think that for medicine to advance further, we can't be afraid of change. What was interesting was when we first started doing awake spine surgery, we started doing it on the simple cases, laminectomies, discectomies. I soon thereafter, I changed jobs and went to work at a private hospital and work with a progressive group of anesthesiologists who had been doing ERAS and other specialties. As I was doing my spinal fusion surgeries under general anesthesia, we were getting faster, more efficient.
One of the anesthesiologists said, "Why aren't we doing spinal fusion surgery under spinal anesthesia?" To be honest with you, I said, "No." I did a literature search to try to figure out whether that's been done. It had not, or at least it had been published. At the time she said, "Why don't we do our spinal fusion surgeries under spinal anesthesia?" I said, "Let's do our spinal fusion surgery under spinal anesthesia." It was truly one of their first awake spinal fusions that we did, and it's been remarkable since then.
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Practical Applications of Awake Spine Surgery
Awake spine surgery is evolving as a viable and effective approach for performing various types of spinal fusion, as demonstrated by global experiences and pioneering efforts. For interbody fusion surgery, Dr. Sharan prefers the transforaminal lumbar interbody fusion (TLIF) performed under spinal anesthesia, emphasizing minimal invasiveness, reduced operative time, and enhanced patient tolerance. Surprisingly, even extreme lateral interbody fusion (XLIF), a fusion procedure conducted with the patient on their side, is successfully performed awake by surgeons across the globe, further broadening the scope of this innovative approach. In some countries with limited resources, such as India, awake spine surgeries are already common as they prevent the need for use of general anesthesia machines that may not be available. As awake spine surgery's applicability transcends geographical and procedural boundaries, embracing the awake methods marks a significant stride in advancing patient care, reducing postoperative complications, and democratizing surgical access worldwide.
[Dr. Jacob Fleming]
Talking about spinal fusion surgery is kind of interesting because obviously, not all fusions are the same. We've got, of course, TLIF, PLIF, ALIF, all kinds of different LIFs. I think every surgeon has their preferred workhorse, and certain of the operations work better in certain cases. Break it down a little bit further for us, which of the lumbar inner body fusion operations are you performing, and which ones are off the table either for obvious anatomic reasons or something that might be a little bit more nuanced?
[Dr. Alok Sharan]
I'll tell you my preference for how to do the inner body fusion, and then I'll tell you how my eyes have been opened to the fact that you can do so many procedures awake. My preference is to do a TLIF surgery, which is essentially going from the back of the spine and fusing, let's say, two levels, L4 and L5. I do the TLIF. I do that less invasively, minimally invasively with small incisions, and we do that under spinal anesthesia. That works out really well because the patients are prone for about an hour and a half. They can handle that really well. That's my procedure of choice.
Now, what's been interesting is that as I've published and spoken more about awake spine surgery, I've been contacted from people all across the world. One thing I've learned now is that you should never say this can't be done because I have a colleague in Italy who's very facile at doing the XLIF procedure, which is essentially doing a fusion while the patient's on their side, and he does them awake.
[Dr. Jacob Fleming]
Wow.
[Dr. Alok Sharan]
He does the awake XLIF procedure. It's sort of interesting how that story came about. During COVID, they got hit really hard in Italy. He was very proficient at doing the XLIF procedure and told his anesthesiologist, "We can avoid intubation," which we know is really critical during COVID. "Why don't we do the XLIF under spinal," and they did, and now he's done over 150, 200 of these cases. I've learned now that there's probably really no procedure that you can't do awake in the lumbar spine.
[Dr. Jacob Fleming]
That's really interesting, and especially because just the degree of degenerative pathology in the lumbar spine, no patient is really the same. Obviously having a workhorse approach is very important, but there are certain factors that will steer you in one direction or the other. To think that even from the lateral approach, can be done, that's pretty exciting. Have you heard of any anterior approach being done awake? That was one of my main questions.
[Dr. Alok Sharan]
Yes. Of course. The ALIF procedure, and as we know, people get C-sections under spinal anesthesia, so they're awake for that. There are many people out there who already are doing that, but essentially, you can do an ALIF awake. You could do an XLIF awake. You could do a TLIF or posterior approach awake. What's Interesting to me is this, I think right before COVID, I was invited to be a guest speaker at the Indian Orthopedic Association, their conference. I remember they had asked me to come speak about my experience doing awake spinal fusion. They're very respectful over there, especially because I was a foreigner. I got off the stage, and a gentleman came up to me and said, "You know, sir, I just want to let you know that we do most of our lumbar procedures awake." I said, "Okay." I said, "Single level, two levels?" "No, like multi-levels." What it came down to was that in the places that are far away from the cities, let's say 300 miles away from the big city, they may only have one general anesthesia machine. The patients have tuberculosis of the spine, they're about to become paralyzed. They need to do the surgery, and so they have no option but to do the surgery awake. I've learned now they say, necessity is the mother of invention. In countries like that, where they don't have the resources that we do, they've learned that there are ways that you can do many of these procedures awake. The truth is we really shouldn't be afraid of doing it. People are doing multi-level lumbar fusions awake.
[Dr. Jacob Fleming]
That's amazing. I think that really highlights just the utility of this approach. Obviously, for our modern healthcare system in the US, we're very blessed in a lot of places to have pretty great resources, and the utility of this approach is pretty obvious. Especially in countries where, like you said, there's maybe one GA machine in the entire hospital.
Patient Selection Considerations for Awake Spine Procedures
As the landscape of awake spine surgery continues to evolve, there is a concurrent broadening in guidelines regarding patient selection. Initially reserved for younger, healthier patients, the awake spinal fusion procedures have now been successfully performed on individuals spanning a diverse age and health spectrum, including a 93-year-old patient. Patients with specific comorbidities, like COPD, may particularly benefit from avoiding general anesthesia. The shift in perspective among hospital staff and patients, propelled by the visible postoperative advantages, further bolsters the preference for awake spine procedures. Patient preference for awake procedures continues to increase as well; Dr. Sharan’s use of terminology when explaining the anesthesic component (e.g. calling the patient’s state "twilight" instead of "awake") helps in alleviating patients' apprehensions, making them more receptive and enthusiastic about the procedure.
[Dr. Jacob Fleming]
Yes. To expand the access for patients who really need fusion surgery, that's pretty amazing. Tell us about picking a patient for awake spine surgery, who's kind of the ideal candidate and what are some factors that might steer you toward or away from the awake approach?
[Dr. Alok Sharan]
Early on when we first started doing this, this is about seven, eight years ago that I started doing awake spinal fusion, we were very selective. Perhaps a healthy 40-year-old gentleman who couldn't stand being prone or [unintelligible 00:13:05] with a 50 or 60-year-old. As our experience got better, as my team and I got better, we realized that we can start doing the awake procedure on people with all different types of comorbidities and all ages.
In fact, now, we're at the point where we just operated on a gentleman who was 93 years old. He had traveled up from Washington, D.C. to us for his surgery. What we're realizing now is that once you have a process in place and you're consistent in your process, any lumbar procedure can be done awake. The only time that we wouldn't do it is if there's an absolute contraindication to spinal anesthesia and if there's an absolute contraindication for them being prone.
As I've learned now, for example, if someone has COPD or some kind of breathing problem, those patients actually may benefit from being awake so that you can avoid general anesthesia. Fortunate that I get invited to give a lot of talks on the topic, and I say that, yes, like everything else, there's a learning curve. You want to start with the straightforward cases in the beginning, build up your experience, and as you do, start expanding your indications. Don't go jumping into the deep end straight away. Start slow, build up confidence, build up confidence with the team.
At this point now, I could tell you this, what's remarkable is that we have to convince our patients but we have to convince our staff why we're not doing it awake because the patients are doing so well after surgery that the nurses in the recovery room would say, "Why did you not do the surgery awake?" For them, it's so much easier when the patients come in, and they're just happy, they have no pain, they don't have that general anesthesia face, you know what I'm talking about?
[Dr. Jacob Fleming]
Yes.
[Dr. Alok Sharan]
Our hospital staff encourage us because they see the tremendous benefit of doing it this way.
[Dr. Jacob Fleming]
That's great. That's really great to hear. Tell us about the patient perspective. When you're seeing the patient in the office and talking them through operation that they need and your approach and everything, when you start talking about awake spine surgery, what's the reaction to that initially, or do some of the patients know about this?
I assume some patients are probably seeking you out because you've made a name for yourself, but surely some patients when they first hear about this, they kind of, "You want to put screws in my back while I'm awake?" [laughter] What am I going to feel?
[Dr. Alok Sharan]
Of course.
[Dr. Jacob Fleming]
Yes. What's the reception to that, and how do they come around?
[Dr. Alok Sharan]
It's a great question, and like everything else, it's been an evolution. I tend to use the word twilight instead of awake when I speak to the patients. Many patients have had like, let's say, a colonoscopy, and they get twilight anesthesia or they've had a dental procedure and they get twilight anesthesia. We don't start with the notion of awake because I think there are a lot of bad connotations around that, that I'm going to be awake during my surgery, and I completely understand that.
What we say to the patients is that, nowadays we're able to do surgery under local and regional anesthesia while giving you twilight medicine so that you'll have no recollection of that. When you pose it that way, the patients actually are enthusiastic about that. We've had patients come to us, like you said, because they need spine surgery and they don't want to be intubated.
Podcast Contributors
Dr. Alok Sharan
Dr. Alok Sharan is the president of Spine and Performance Institute in Edison, New Jersey.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2023, July 5). Ep. 18 – Awake Spine Surgery [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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