Preparing Patients for Awake Spine Surgery: What to Expect Before, During & After

[Dr. Alok Sharan]
The day of surgery, they go through the typical routine of checking into the hospital, getting ready, changing their clothes. I'll meet them, obviously, outside the operating room. The anesthesiologist will meet with them. Often, I'll try to speak to the patient with the anesthesiologist so that they feel comfortable about what we're going to do, then we roll them into the operating room. Typically, at that point, we may give them some medicine to forget the whole experience. At that point, what we first start by doing is a spinal anesthesia, so they're sitting up on their stretcher. As soon as the spinal anesthesia is done, what's neat is the patients actually position themselves prone on the OR table. Now, that's important because we know in spine surgery, being prone has some risks associated with it. If you don't position their arms, they can get brachial plexus injuries. If you don't position their eyes properly, they can get issues with that. What's neat about this is that the patient actually positions themselves in a very comfortable manner. This goes back to the whole notion of trying to deliver a better experience. What I learned early on was that when a patient is under general anesthesia, we're taught a different way of sort of how to position the patient, but many people have shoulder problems, rotator cuff issues. They may not want to position their hands in the way you think they want to. They want to position their arms in a way that's comfortable for them. That's a subtle point, but just understand that you're basically going to help the patient dictate how they're going to feel with their arms during the surgery, which adds to the better experience, so that when they wake up, they're not complaining of shoulder pain, even though you did a low back surgery. That's neat, right? That was a learning point for me.

Many of our patients come in, and we ask them to bring in their headphones so they could listen to music. Some patients opt to bring in headphones. At that point, we actually set up their music, which I think is actually really interesting. I've heard some really interesting playlists from the patients as a result of that. Then the other thing which is novel and part of the neat thing about the evolution of what we're doing is, in spine surgery, we've been slower than the rest of our orthopedic colleagues to adopt these regional blocks. My colleagues who do knee replacements, they do some incredible regional blocks around the knee. But 10 years ago now, there was a paper published around some new regional blocks, which we started adopting. I use a medicine called Expro, which lasts for 48 hours. At that point, we do our regional block, which has really been a game changer because these patients wake up with no pain after the spinal fusion. Then we go ahead and do our surgery, which is typically about an hour and a half.

To be honest with you, I don't have anything fancy to do the surgery, robots, navigation. We use x-ray and just use standard tools. And that's why I always tell people that you really don't need to do anything fancy to be able to achieve a good spinal fusion. Patients are very comfortable. An hour, hour and a half later, when the surgery is done, we've timed our surgery such that when we give them the spinal anesthesia, the spinal anesthesia wears off typically as the surgery is being completed. So that when we turn them onto their back, they're getting ready to wiggle their toes. At that point, they know this because we've already cautioned them that a couple hours later, the numbing medicine will wear off. We have a whole protocol that we follow in terms of pain management. About four hours later-- this is the fun part. About four hours later, the nurse will typically get them to sit up and stand up, and that will often be the first time that they stand up with no pain. It's an eye-opening movement. It's also remarkable to see their faces because they're ready to have pain, right? They just had a spinal fusion. They had screws in their back. They wake up and they say, there's no pain. That's amazing to see.

[Dr. Jacob Fleming]
That's amazing, especially when they've probably been dealing with low back pain for quite some time to kind of flip the switch like that. That's an amazing moment.

[Dr. Alok Sharan]
It's an amazing moment.

[Dr. Alok Sharan]
My practice is such I don't typically do deformity surgery. I used to in my previous life, but I don't anymore. The majority of the patients I take care of have single-level or multi-level disease, so that's typically an hour, hour and a half surgery. Then they're typically in the recovery room for four hours is what we aim for. We have a whole protocol so that at hour one, we do one thing, at hour two, we do another, three, four. The reason why I keep on bringing up the four-hour issue is because they've shown in the ambulatory surgery world, ASC, that the cost-effectiveness of a procedure starts to diminish after four hours. If you want to define your efficiency, you want to basically be able to discharge the patients home by four hours on average. That's why our protocol is designed that way. Then they typically go home, they walk home, and they walk the next day.

My staff and I are very good about calling the patients either the day of, the next day. As I mentioned before, you have to have multiple touchpoints with the patient, especially since they went home the same day. Sort of coaching them through their period, how to get through the pain, any issues they deal with. That typically, for the first 24 to 48 hours is probably the most intense period, but then it really drops off after that. I know that patients don't require pain meds after about four to five days for two reasons. One is that we have the state database so we can see if they're getting medicines from anybody else. Then two, I typically only write them for pain meds for about four or five days, so I'm the one getting the phone calls if they need more medicine. It's a fairly consistent number that they only require pain meds for that short period of time, which is great. I can foresee that there'll be a time when we can make this an opioid, a complete opioid-sparing surgery. I mean, to think that we could do a spinal fusion and not do opioids, that's not going to be too hard of a challenge to do. We'll get there in time.

[Dr. Jacob Fleming]
Yes, and definitely would be a game-changer. Obviously, everyone's very focused on the risks of opioids. A lot of the research has shown that if it's used for acute pain related to surgery, the risks of chronic dependence are low, but obviously, just minimizing that as much as possible is the goal, I think. Tell us a little bit about what's kind of the typical postoperative pain regimen that you're sending patients home with?4

[Dr. Alok Sharan]
What we typically do is give them some type of opioid, whether it be a Vicodin or a Percocet. We give them a muscle relaxant. We give them antibiotics, and we give them stool softener. That was sort of an interesting thing that we picked up on is that especially elderly gentlemen, they tend to have problems with bowel function after surgery. We actually start them on stool softeners prior to surgery, and that's made a big difference so that they have less problems after surgery. That regimen is maintained for about a week in terms of the stool softener.

In terms of the pain management, it's typically for 48 hours. We give them the narcotics and the muscle relaxant, and then on day three and day four is when they really start to slow down. They typically see us in the office about a week after surgery. At that point, they're not taking much more medicine. At most, they'll be taking a Tylenol extra strength.

[Dr. Jacob Fleming]
That's pretty amazing, just to say that within a week of spine surgery, the patient will just be taking Tylenol. I'm sure you can probably compare that to some of your earlier experiences with operating on patients before in the old way of GA and being on longer courses of medication. I imagine that must be pretty amazing.

[Dr. Alok Sharan]
It's neat on a couple levels. One is that our data right now for full transparency, our last review is that 70% of patients are off of narcotics after one week from surgery. The 30% who are not, who are still on opioids, were opioid-dependent prior to surgery. We're not at 100%. If you're opioid naive prior to surgery, by one week's time, great confidence that you'll be off of narcotics. More than anything else, the beautiful thing about the whole thing is that I get less phone calls after surgery because the patients aren't in pain anymore, and that's been a game-changer for me.