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

Author Taylor Spurgeon-Hess covers Preparing Patients for Awake Spine Surgery: What to Expect Before, During & After on BackTable MSK

Taylor Spurgeon-Hess • Nov 1, 2023 • 32 hits

The implementation of awake spine surgery offers patients the option to avoid general anesthesia, and opt for local and regional anesthesia instead, while undergoing their low back surgery. This reimagines the surgical experience, underlining patient comfort and empowerment during each phase. An emphasis on the patient’s comprehensive understanding of the procedure and the implementation of patient self-positioning after spinal anesthesia minimizes risk and increases patient satisfaction. Postoperative care integrates rigorous pain management strategies. A short opioid course combined with other medical aids can help to ensure a smooth recovery process without extensive narcotic usage.

This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable MSK Brief

• After spinal anesthesia, patients position themselves on the operating table, minimizing the risk of positioning-related injuries and ensuring their comfort. Typical cushions and a Wilson frame are used to augment patient comfort without the need for more complex tools.

• Surgery is timed precisely, aligning with the wearing off of spinal anesthesia, enabling patients to awake and move with minimal to no pain. The adoption of regional blocks, including the use of Expro, significantly reduces postoperative pain.

• Within hours post-surgery, patients are assisted to sit up and stand, often experiencing no pain for the first time in an extended period, signaling a positive start to the recovery process.

• Patients are given the chance to adjust their position during surgery, maintaining comfort and reducing potential complications.

• A typical postoperative regimen includes a short course of opioids, muscle relaxants, antibiotics, and stool softeners. The introduction of stool softeners prior to surgery, especially for elderly patients, effectively minimizes postoperative bowel function issues.

• The data for awake spine surgery shows a promising trend with 70% of patients discontinuing narcotics one week post-surgery, indicative of the effective pain management strategies implemented.

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

Table of Contents

(1) A Patient-Centered Approach to Awake Spine Surgery

(2) The Power of Patient Positioning in Awake Spine Surgery: Enhancing Comfort & Outcomes

(3) Awake Spine Surgery Recovery: Postoperative Care & Pain Management

A Patient-Centered Approach to Awake Spine Surgery

The day of surgery unfolds with a routine check into the hospital for patients, yet it is far from a typical experience. An emphasis is placed on ensuring the patients' comfort and understanding of each step in the procedure. Patients are met by the surgical team, including the anesthesiologist, to review the procedure and answer questions. The awake spine surgery approach allows patients, post-spinal anesthesia, to position themselves on the operating table, ensuring their comfort and minimizing the risk of positioning-related injuries. This attentiveness to patients’ comfort extends to allowing them to listen to their own music during surgery. The use of a long-lasting regional block medicine, Expro, aids in significantly reducing post-surgical pain. The entire process is meticulously timed, ensuring that the spinal anesthesia wears off just as the surgery concludes, allowing patients to wake up and move with minimal pain, often for the first time in a long while, marking a remarkable moment in their recovery journey.

[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.

Listen to the Full Podcast

Awake Spine Surgery with Dr. Alok Sharan on the BackTable MSK Podcast)
Ep 18 Awake Spine Surgery with Dr. Alok Sharan
00:00 / 01:04

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The Power of Patient Positioning in Awake Spine Surgery: Enhancing Comfort & Outcomes

In awake spinal surgery, the spotlight shines on patient comfort and the reduction of movement-related complications during surgery. Dr. Sharan highlights the paramount importance of patient self-positioning. By utilizing insights from smart mattress technology, pressure is minimized, enhancing comfort and limiting unwanted patient movements during the operation. This patient-centered approach lays the foundation for a controlled surgical environment where patients actively communicate their comfort levels, making necessary adjustments to ensure stability throughout the procedure.

[Dr. Jacob Fleming]
It sounds like one of the questions I had is whether patient movement is an issue. This is something we think about in IR all the time. Certain procedures we're doing, for example, a lung biopsy, we have to think about, okay, can we do this under moderate? Is the patient able to hold their breath consistently and these kind of things? Based on what you're saying with the spinal and the block, I'm guessing you're probably not having too much issues with the patient truncal movement or anything like that. Are there any issues that may come up related to patient movement?

[Dr. Alok Sharan]
It's a great question because, I'm doing spine surgery, I'm right near the nerves. If the patient were to move, of course, that could be tragic. This is sort of a fascinating story, but I learned a lot about patient positioning from a patient who I took care of who worked for a mattress company. Now, mattress companies are fascinating because smart mattresses, what's their goal? Their goal is for you to wake up and have a good amount of sleep. They know that if you, for example, I never got the numbers, but they know that if you feel a certain amount of PSI for a certain period of time, let's say 10 PSI for 15 minutes straight, you're more likely to turn over. They've shown that the more times you turn over, the worse your sleep is. Smart mattress companies will modulate it so that around minute 12 or 13, they'll decrease the pressure, right, so that it's 8 PSI and that you won't turn over. They've shown that the more comfortable you make that, less likely you'll turn over, the better your sleep is. By having the patient position themselves prone, be able to really tell you how comfortable they are, they're less likely to turn over. You don't need to turn over. You don't need to move if you're comfortable. In a situation like let's say what you're describing with the moderate sedation, you have to sort of let the patient pick a comfortable position, an hour or two hours, whatever it's going to be, and of course, have right material so that they're not necessarily on a hard surface. If you do that, you'll be surprised how still the patients can be if they're comfortable.

[Dr. Jacob Fleming]
Yes, absolutely. Are there any implements, you know, different people have different things, like the jello mold or just folded pillows or anything like that? Any kind of things that you use in the operating room to help the patient get positioned in a comfortable manner?

[Dr. Alok Sharan]
Yes, it's a great question. I think that honestly, it would be the business plan to create better materials that patients can have to make them comfortable. We don't use anything fancy, not yet. At least right now, we use the typical cushions associated with that, and then the biggest thing is we use a Wilson frame, which is very comfortable.

Also, it's opened, so then they're not feeling the pressure too much over there. Then the other thing is that if we do think the patient is going to feel uncomfortable, in the middle of the case we'll ask them, do you want to adjust yourself? We stop, and the patient can adjust themselves and put themselves back into a better position.

Awake Spine Surgery Recovery: Postoperative Care & Pain Management

In awake spinal surgery, efficient postoperative care and pain management are paramount, as outlined by Dr. Alok Sharan. The protocol follows a four-hour stay in the recovery room, maximizing both cost and clinical efficacy. Consistent postoperative communication aids in addressing patient concerns and ensuring their comfort and understanding of the recovery process. Initial pain management includes a short course of opioids paired with muscle relaxants and antibiotics. A stool softener regimen started prior to surgery can preemptively address potential postoperative bowel issues, particularly in elderly patients. This pain management approach aims to swiftly taper opioid use, with a notable 70% of patients discontinuing narcotics within a week post-surgery.

[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.

Podcast Contributors

Dr. Alok Sharan discusses Awake Spine Surgery on the BackTable 18 Podcast

Dr. Alok Sharan

Dr. Alok Sharan is the president of Spine and Performance Institute in Edison, New Jersey.

Dr. Jacob Fleming discusses Awake Spine Surgery on the BackTable 18 Podcast

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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