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BackTable / MSK / Podcast / Transcript #18
Podcast Transcript: Awake Spine Surgery
with Dr. Alok Sharan
In this episode, Dr. Jacob Fleming interviews Dr. Alok Sharan about low back awake spinal surgery. This innovative approach offers patients a more pleasant surgical experience compared to traditional surgery under general anesthesia. Not only does it provide better patient outcomes, but it also reduces the need for opioid pain medication and allows for improved mobility after the procedure. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Defining Awake Spine Surgery
(2) Suitable Procedures for Awake Spine Surgery
(3) Patient Selection for Awake Spine Surgery
(4) Preoperative Counseling & Virtual Reality Integration
(5) The Day of Surgery: A Walkthrough
(6) Patient Positioning & Comfort Considerations
(7) Postoperative Medications & Management
(8) Implementation Challenges & Successes
(9) Awake Spine Surgery & The Evolving Healthcare Landscape
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[Dr. Jacob Fleming]
This is your host, Jacob Fleming. I'm a radiology resident in Dallas, Texas. Today, I'm enthused to welcome to the show orthopedic spine surgeon, Alok Sharan. Dr. Sharan, welcome to the show.
[Dr. Alok Sharan]
Thank you. Thanks for having me on.
[Dr. Jacob Fleming]
Thank you for coming on. I have to say, the goal of this show is to talk about everything that's the latest and greatest in MSK fields, inclusive of radiology, orthopedics, spine surgery, neurosurgery, and everything. I can't really think of a better way to start than talking about awake spine surgery, which I think is a topic that grabs a lot of ears right off the bat. I'm excited to dive into this topic today. Dr. Sharan, before we begin, just tell us a bit about your background, your origin story, getting into medicine, and when you knew that you needed to be a spine surgeon.
[Dr. Alok Sharan]
Sure. Thank you. No, I appreciate that. I'm an orthopedic spine surgeon. I've been in practice now for about 16 years. I'm currently in private practice in New Jersey, but it didn't start out that way. I did my college at Boston University. I was actually a political science major, and then I decided that I wanted to go into medicine because I enjoyed the ability to impact and help people. I went to medical school in New Jersey, residency in Upstate New York, fellowship in NYU, then I started my career off in academic medicine at a wonderful academic hospital called Montefiore in the Bronx. It was a wonderful experience for me. I had a chance to really take care of people with severe back problems who needed spine surgery. Towards the tail end of my time at Montefiore, I realized that I wanted to get a healthcare MBA, which I did. I got a healthcare MBA at Dartmouth, and it was around the time that Obamacare had passed and things were being implemented, and I realized that healthcare was changing. At that time, I realized that I didn't want to be in academic medicine anymore, and then made the shift to private practice. It was sort of interesting in that I got this great healthcare MBA, and ended up not going into academics, which is really sort of the opposite of what most people think, but it's been an incredible ride since then.
[Dr. Jacob Fleming]
That's really interesting. I'm sure your backgrounds in the healthcare administration definitely gives you very interesting insight into this particular topic, which has a lot of advantages outside of just a single patient kind of doing well. With that said, let's get sort of a 40,000-foot view of what is awake spine surgery.
(1) Defining Awake Spine Surgery
[Dr. Alok Sharan]
Right. 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.
[Dr. Jacob Fleming]
That's fantastic. 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?
(2) Suitable Procedures for Awake Spine Surgery
[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, I mean, that's--
[Dr. Alok Sharan]
Yes. Incredible?
[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?
(3) Patient Selection for Awake Spine Surgery
[Dr. Alok Sharan]
Yes, that's great. That's a great question. 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.
It was interesting because COVID to a large degree helped us because the issues associated with getting intubated were really highlighted during the COVID period. Now patients I think are so much more attuned to the notion that you don't necessarily want to be intubated if you don't have to be. As a result, we've had patients-- we had a gentleman who came to us from Michigan. He had previously had a knee replacement, was intubated, and unfortunately, during the intubation, had an injury to one of his nerves that go to his vocal cord.
He just could not be intubated because if he did and they knocked out the other nerve, he would have had difficulty breathing and speaking. He specifically sought us out because he needed to have his spine surgery done under local and regional anesthesia. What I also say for many other patients is that, while the notion of avoiding general anesthesia is what may bring them in, I also say to them that the other benefit is that because we're doing a regional block on top of the spinal anesthesia, using a medicine that lasts for 48 hours, then as a result, you really have minimal pain.
Many of our patients take narcotics really just for a few days. I mean, my understanding is the CDC says that about 80% to 90% of patients are on narcotics for four to six weeks after spinal fusion surgery. That's the national average. On average, our patients are on narcotics for only four days. For patients who want to have opioid-sparing spine surgery, it's also been a great option for them.
[Dr. Jacob Fleming]
That's wonderful. It sounds like it's not too onerous to explain to the patient the benefits of this. Let's actually talk about the day of the surgery. Tell us about what's the setting that you're operating in? Are you in a sort of acute care hospital setting or an ASC?
(4) Preoperative Counseling & Virtual Reality Integration
[Dr. Alok Sharan]
Yes, I'm in both settings. I work out of a couple of different hospitals and then work out of some ambulatory surgery centers. The ambulatory surgery centers, we typically do the smaller surgeries, so we'll do the awake laminectomy, awake micro cystectomy, and the awake spinal fusions we're doing in a hospital. I imagine at some point, it'll become routine to do these at an ASC. One thing I want to say is that the day of the hospital is a fairly routine thing. What's not routine though is a lot of the counseling and education we do with the patients prior to surgery.
When you're doing outpatient surgery, I think it's really critical that you have many different touch points with the patient, both before and after surgery. It's really critical for them to understand that we're doing all this so they can mobilize quickly. We tell the patients that you're going to have your surgery, and four hours later, we're going to get you up and walking, getting ready to go home. Then, we tell the patients that you're going to have the twilight anesthesia and you'll have no recollection of it, and we counsel them on that.
It's kind of interesting because we're getting to the point where we're going to start developing a whole pre-op education program and give the patients a virtual reality headset. They'll be able to walk through the day of surgery and the surgical procedure themselves, be immersed in it. What we're aiming towards, what we're building right now is a sort of content where patients can wear the headset, and that's what their education is going to be.
In my experience, the more the patient knows, the more they can anticipate. Then the greater you can reduce their fear and anxiety going into the surgery, the greater your outcome is going to be. A lot of times, I think that when people think about awake spine surgery, awake spinal fusion surgery, outpatient surgery, they focus on the technical part of it. By no means am I trying to belittle that, but I don't think people will appreciate how much pre-work goes into it to get the patients to not only be able to go home the same day, but also have a superior outcome as well.
[Dr. Jacob Fleming]
That's really cool. I really like to hear that, especially that part about the VR. There's a lot of buzz in medicine, and especially, surgery and IR about places where we can integrate VR. It's more on the operator side is more we're focusing on it, but I've seen a few things. Then what you've just mentioned now about using it for the patient benefits specifically, that's really fascinating to me because the notion about surgeons sort of practicing through how everything's going to go in their head so that they get to the operating room and doing that, thinking about how that same thing applies for the patient too. For them to be able to virtually walk into the hospital and to pre-op and know how everything's going to go, it's pretty obvious to think about the benefits that could follow from that. Especially something like this where, like you said, the counseling is so important to have, everyone kind of at the same level and avoid surprises about-- and just have good expectations, it sounds like that's absolutely crucial to the mission.
[Dr. Alok Sharan]
It's absolutely crucial. Yes, it's really interesting. There's so many different avenues about that because, as you know, as I mentioned earlier, I got my healthcare MBA up at Dartmouth. That was at a time when many of the individuals who developed a lot of these value-based programs were doing work on that. We spent a lot of time talking about outcomes in health care and how do you measure it. I think that's this big debate over there. To me, the best outcome is one where the patient says that they're satisfied and that they want to tell five of their friends about the experience. That's the net promoter score. That's a simple thing. We can talk about what outcome instruments you want until the sun sets, but in my mind, it's about achieving such a great outcome that they want to tell their friends and relatives about the procedure. In doing that, you have to appreciate not only the technical aspects of it, but you have to appreciate some of the emotional aspects about the procedure itself. It's been shown pretty clearly that if patients have a tremendous amount of fear and anxiety going into a surgical procedure, their outcomes are inferior than those who didn't.
That's amazing because you could do the best surgery in the world, and I've been there before. I've done the best technical procedure, and the patient is like, "Aargh, I don't feel well." I said, "Yes, but your X-ray looks beautiful." I've been there before, and now I realize that the missing link is that they weren't there emotionally. If you're really trying to aim for an outcome where they want to go out and tell five of their friends, you have to start looking into these factors as well.
[Dr. Jacob Fleming]
Oh, that's really interesting. I think I'm going to be thinking about that for the rest of the week. I mean, there's just so much that goes into it, and it's like the old adage is, just any old day at the hospital for us, it may be the scariest day of the patient's life, and especially something that can be as emotionally charged as spine surgery. I think it makes a lot of sense why the counseling and innovating how we can deliver that in a more optimal way, that's just really interesting. I think that the whole VR topic, I think that could be a whole episode on its own we may have to do.
[Dr. Alok Sharan]
We do, yes. I'll just give you just a brief preview that I am working with a company called Wide Awake VR, who's done a lot of good work on giving people a virtual reality headset while having hand surgery awake. They've done some good published work now, showing how something as simple as hand surgery, where you think the outcomes are pretty straightforward. I mean, how much improvement can you get for hand surgery?
Even in that particular scenario, they've shown that when you put them on, if you're on a VR headset, let's say they're watching elephants walking through a safari in Africa, that even in that kind of scenario, you can modulate how they feel, and then the outcomes, as reported by the patients, are better, which blew me away because, again, I thought that, hand surgery, how much more benefit can you get? Overall, the outcomes are pretty good. Then you realize when you start adding in the emotional component and how you can modulate that with VR, you start realizing, reaching a different level. Ultimately, at the end of the day, I know many people are fascinated by the notion that I can do the surgery awake and send them home in four hours. To me, it's going to be really interesting when I can really modulate the experience of the surgery itself so that patients come out and they feel like they had a great time. Let's say they were watching a virtual reality headset while they're having their spine surgery. That to me is what we're driving towards now.
[Dr. Jacob Fleming]
That's so cool. Yes. I really can't wait to hear how that goes, because one of the things I did want to talk to you about, we'll touch on a little bit, is kind of the ancillary things in the OR to make the patient feel a little more at ease, and so putting in the VR aspect of it, I just see so many possibilities on that. That's really cool. Really interested to see where that goes in the next few years. Let's talk a little bit about the patient's experience, since we're talking about that. They check into the hospital, and what's the process on the day of surgery?
(5) The Day of Surgery: A Walkthrough
[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.
(6) Patient Positioning & Comfort Considerations
[Dr. Jacob Fleming]
That's really cool. You answered a lot of the questions I had already about in terms of positioning. 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.
[Dr. Jacob Fleming]
Nice. That's good. Yes, that actually brings up one question that I had. You sort of alluded to this is pretty much going to be one or two-level surgery. I was just wondering, is there a way that navigation or robotics could fit into this picture? Obviously, with navigation, typically starts with, if you're doing an O-arm CT acquisition at first, a problem we run into with some of our interventions in IR where we may start with a cone beam CT and then do guidance type of things is if the patient moves, that CT may no longer be useful. That was one of the issues that I saw potentially related to that. Is there a way that you think navigation could be ultimately implemented with awake surgery?
[Dr. Alok Sharan]
Yes, it already is. I have a colleague down at the Mayo in Florida, another colleague at Duke who are doing awake robotic surgery. They're already using the robot to navigate the screws. They've shown really clearly, I don't think they're using the O-arm, but they're getting their image acquisition in other ways, but regardless, they're able to put in the screws using the robot. You can foresee that, right? Doing a multi-level fusion won't be a problem because the robot, obviously they're very quick in putting their screws in so that it won't be a problem to be able to do an L1 to S1 fusion with the robot.
[Dr. Jacob Fleming]
That's amazing. That's really cool. Most of what you're doing, like you said is like one or two-level lumbar fusion, and so typically, how long is the operation lasting for? Then you say you get the patient in the PACU, and then what's their typical stay? I know you alluded to some of this earlier.
(7) Postoperative Medications & Management
[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.
[Dr. Jacob Fleming]
Yes, that's great. I mean, obviously, patients love not having to call the office because they're not having an issue. That's a win-win.
[Dr. Alok Sharan]
It's a win-win really.
(8) Implementation Challenges & Successes
[Dr. Jacob Fleming]
What have been some maybe unexpected challenges or pleasant surprises implementing the awake practice?
[Dr. Alok Sharan]
That's a great question. From a technical point of view, our protocol is down. The bigger challenge is dealing with the cultural issues. What I mean by that is the resistance to change from, let's say, my anesthesiologist or people in the OR, and trying to figure out how to win them over. I've had the chance now to do awake spine surgery at multiple different hospitals, so I'm not just with one place. I've had to learn change of management in this context. To me, that's been the hardest things.
I know that this is a better way of doing spine surgery, but the person at the other end behind the drape doesn't, and so trying to sort of work with them and convince them that this is the right way to do it. Where it's becoming really interesting for me is that I've had a chance now to teach the technique to people across the country and across the world. I just recently had some visitors from Oxford, England come over. The English healthcare system is very regimented, very standardized, very protocol-based. It's quite incredible. Very resistant to change for that reason.
It's been interesting for me to not really think about how people are doing awake spine surgery in these countries, but how they're dealing with the cultural change issues, the change management issues. Each place is unique and different, but I'm proud to say that now they've done about 30 awake spine surgeries in Oxford, and it took them a while. It wasn't an issue about the technical part of it. Everyone knows how to do the spinal and the block. It wasn't an issue of doing the surgery. It was an issue of getting everyone to come on board to the idea. That's been the biggest challenge that I've seen with all this, it's just managing change.
[Dr. Jacob Fleming]
That's something that just takes time, I think. It's been interesting. I've noticed comparable things just even in my training is that you can see, "Oh, why do we do something this way?" Everyone will kind of shrug their shoulder. I don't know. It's just how it's been since I've been a resident here, and then I was a fellow, and now I'm an attending here, and we still do it that way. Yes, there's a lot of inertia is you have kind of some strategies toward getting people on.
I mean, surely a lot of it is just doing one case at a time, and people will come around once they see that the outcomes are superior and the benefits to it. That initial push, though, can be quite difficult. Were there some sort of strategies that you employed maybe when you were doing your first awake case at a hospital, anything that you found to be particularly effective?
[Dr. Alok Sharan]
Yes, I think a couple of things. One is that from my personal perspective, I tended to try to find anesthesiologists who are very comfortable doing spinals, so particularly the ones who do OB-GYN. They feel more comfortable. Then, generally, the younger anesthesiologists tend to be a little bit more open to change, not too young, but a little open to trying it out. I've been lucky that I've been able to find those people pretty quickly, so I don't need to spend too much time convincing them, and really just working on more of the technical part.
In the larger context, at Dartmouth, we learned about the innovation curve and the adoption of innovation, Moore's curve, essentially. Now when I teach people, a lot of times people will call me and ask me about the technique and whatever, and I actually put a pause in it. I try to really understand where they are in that adoption curve. Are they the innovators, the early adopters, or are they a laggard? Because then I know, look, if you're a laggard or if you're surrounded by laggards, you're not going to be doing this. For me, it's been really helpful to sort of segment my student, if you will, and be able to teach them accordingly because for some people, I can say, look, I want to teach you how to do an awake spinal fusion, or for some people say, look, just do an awake laminectomy on a 30-year-old gentleman with a herniated disc and just do that 20 times. If you don't get confidence in your OR team, it's going to be really hard for you to move forward, and that's been a really good learning curve. We're working a lot right now on scaling up what we do via courses and lectures and so I've learned a lot about the adoption of innovation as a result of all this.
[Dr. Jacob Fleming]
Fantastic. What were some maybe unexpected pleasant surprises you've had during all of this? You mentioned the fewer phone calls, which is great. Anything else?
[Dr. Alok Sharan]
There's been so many, but, you know, as I said before, my goal is to make surgery a pleasant experience. There's been so many patients who I've seen who avoid surgery because of the notion of surgery. I get it. I mean, having surgery is not the first thing you think about, but one of the nice compliments I've had is patients who I've done, let's say, an L5-S1 laminectomy on them.
They did great, I did it awake, and two, three, four years later, they may develop spinal stenosis two levels above, L3-4. I say, okay, let's do physical therapy. Maybe we'll do an injection. Oftentimes, they'll come back and be like, "Surgery was such a good experience. Why don't we just rush into surgery and do that because we know it's going to work? That just shows me that basically we can do it. We made it such a good experience that there's no fear. They're willing to skip the line and go straight to surgery.
[Dr. Jacob Fleming]
Yes. Well, that's really huge because I'm sure you encounter this quite a bit, patients who've been operated on by other surgeons. I've even had that some patients said, "Oh, yes, I had spine surgery." The way they talk about it is not as glowing as what you're talking about. To be able to turn something like that that can potentially be quite an unpleasant experience and memory into something that they're like, "Hey, let's just do it. Let's just take care of it because we know it's not going to be a bad experience and it'll work. That's fantastic.
[Dr. Alok Sharan]
Exactly. That's what our goal is, right? I can tell you so many stories of people who avoided surgery and they got worse just because of the fear of surgery. If we can make it a good experience, that won't be an issue.
(9) Awake Spine Surgery & The Evolving Healthcare Landscape
[Dr. Jacob Fleming]
Definitely. One thing I'd like to hear about, and your perspective on this is so valuable because of your background in health care administration and your perspective from that level. What role do you think awake surgery is going to play in the changing American healthcare system, and specifically, we have an aging and sicker population. Do you think that more surgeons are going to need to incorporate this to take the best care of their patients?
[Dr. Alok Sharan]
Yes, I think so. That's a great question, and it could be answered on so many levels. At a very basic level, as a population ages, the demand for spine surgery will increase. That's just normal wear and tear. We're going to need to come up with a more cost-efficient way of doing spine surgery, so moving it from inpatient to outpatient is one. Moving from general anesthesia to regional anesthesia is two. Making it safer in terms of less opioids.
We've already published a paper showing that when you do the surgery awake versus general, the laminectomy is cost savings. Then we have some prelim data that for the fusions, of course, it's tremendous savings. The number is anywhere from 30% to 50%, depending on how you look at it. No question that it's a cost-effective solution. It's like the hip and knee replacement world. I mean, more patients will undergo hip and knee replacements. You want to do it in a cost-effective way. Otherwise, we're going to bankrupt the system.
I would guess that a lot of change is going to happen when it becomes patient-driven, and to some degree, the insurance companies will follow. I can foresee a time when patients will want their surgery to be done awake, so that's going to cause surgeons to learn the technique. Then the insurance companies will ask for it as well because they'll say, hey, look, we're seeing that our data is such that these patients are doing better. We're not going to authorize a surgery. This is scary, but we're not going to authorize a surgery unless it's being done using this awake protocol.
I can foresee that those are the two drivers that are going to change it. Surgeons, young surgeons will want to adopt it because it leads to fast recovery. From what I can see across the country and really across the world now, it's patient demand which is really causing the change, and then it will soon be insurance-driven as well.
[Dr. Jacob Fleming]
Yes, really, really interesting to think about that. From what I can understand, the snapshot where we are right now, you kind of talked about the Moore's curve, we're still on the relatively early end of that. I think it's going to be very interesting over the next few years to see the propagation of this technique. For all the benefits that you talked about, it's clear to me, it's definitely going to spread. On that note, do you have some words of wisdom and advice to surgeons who are thinking of incorporating this? Maybe more importantly, any thoughts for the naysayers?
[Dr. Alok Sharan]
There's a lot of naysayers. It's okay to be a naysayer. Look, at the end of the day, the goal is to get a good outcome, right? As long as you're getting a good outcome in a safe manner, it's perfectly fine. The challenge becomes when there's a better way of doing things, and that's going to happen. We shouldn't be afraid of change, right? We shouldn't be afraid of progress. That's the only way that the country will advance. It's the only way we're going to become better. I would argue that's what the goal of value-based care is to sort of move that direction. In terms of surgeons who want to learn the technique, I've got to do a better job of creating courses. I've just been so busy with my prior practice that I haven't done that, but we're in the process now of trying to develop some courses around this because there's a lot of interest, not only across the US, but really across the world, because I found that the same challenges that we have over here, countries across the world like England, Spain, Italy, India, Vietnam are having the same kind of challenges. In due time, we have to do a better job of teaching people in a way that's scalable. That's what my next challenge is going to be with all this, beyond developing the virtual reality headset and all the other things that we're doing as well.
[Dr. Jacob Fleming]
Yes, with all your abundant free time.
[Dr. Alok Sharan]
Yes, exactly.
[Dr. Jacob Fleming]
No, it's really cool to hear about this because, when first hearing about this, it just seemed like, "Okay, yes, that's kind of a cool thing, you know, and sort of in the OR, but then as you've talked about this, it's clear it's so much more than that. It goes deep into the healthcare systems, goes into the patient experience before and after. There's a lot that kind of needs to be tuned up. I really look forward to hearing about this as it propagates and really thank you for coming and sharing your thoughts on this.
[Dr. Alok Sharan]
Thank you, again. This is a great podcast and I really enjoyed this conversation. What I want to point out is that it's not just a surgical technique, right? It's about delivering a better experience. Ultimately, that's what my goal is, is when people ask me what's the end point, my goal is that someone comes out of spine surgery and says that was a great experience. If we could achieve that, whatever mechanism is going to be, minimizing opioids, minimizing pain, virtual reality, that would be success in my mind.
[Dr. Jacob Fleming]
Beautiful. One thing that I like to ask all my guests is, obviously you have a lot of passion about this topic in awake spine surgery, but what's the number one biggest thing in medicine that's exciting you right now? Whether that's an aspect of this or something totally separate, what's really getting you excited right now?
[Dr. Alok Sharan]
What's really exciting right now is this whole ChatGPT and adaptive AI. I cannot wrap my head around it yet to understand how it's going to be used. I mean, there's so many different ways it's going, and then the fact that there's pushback on it too. I think it's very exciting. I don't know where it's going to go. I think it's good. I think we've got to figure out which direction it's going to go. There's going to be a lot of ethical and regulatory issues that come up with it, but to me, that's really going to be pushing the needle more than anything else right now in healthcare.
[Dr. Jacob Fleming]
That's a really cool topic, and that's one that I just keep seeing so much around LinkedIn. I'm like, "Man, I really got to start learning about this because it's just accelerating so quickly." That'd be really cool to see where that goes. I'm sure it has some applications to awake spine surgery as well.
[Dr. Alok Sharan]
Absolutely.
[Dr. Jacob Fleming]
It will, I'm sure. I just haven't figured it out yet. Well, we'll ask ChatGPT, what are the applications in awake spine surgery? [laughter] Well, Dr. Sharan, thank you so much for your time. I really enjoyed our conversation. Really hope to have you back on the show in the future. Would love to hear more about the VR as that develops. Thank you so much for your time. Before we sign off, where can listeners keep up with you and learn more about awake spine surgery if they're so interested?
[Dr. Alok Sharan]
Thank you. First of all, again, thank you again. Great podcast, great conversation. We have a website called awakespinalfusion.com. I try to do a good job of updating it so we could put more information on. We actually did create an online learning platform called docsocial, doc.social If people go there, there's actually some lectures and a course that we put up there as sort of a beginner attempt to sort of learning about that. Then LinkedIn, of course, we do a lot of work. LinkedIn is a great professional platform. I do try to put up articles from others who are doing research around it. I find that to be a very helpful resource for getting information. Those are really the three main places where I would say people can go to, to get more information.
[Dr. Jacob Fleming]
Fantastic. Well, again, Dr. Sharan, thank you so much. We'll look forward to having you back on the show in the future. To our listeners, thanks for tuning in, and we'll catch you all next time.
[Dr. Alok Sharan]
Thank you.
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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