Awake Endoscopic Spine Surgery

Speaker 1So, I, as I've mentioned before, when we started doing a wig Surgery, we just, I just really thought about it from a laminectomy, discectomy point of view, really basic surgeries. And what, what's been absolutely incredible to see is how many people are applying it in many different ways. Um, this is Doctor Paul Hu. He's a Spine surgeon up in uh Cape Cod. Um, we're gonna play this video and then Doctor Hu will get in, he'll pipe in live. Um, Doctor Hu just recently operated on an anesthesiologist.

Speaker 1And the video is Doctor Hu discussing um his Awake Surgery and what the experience is like. So why don't we go ahead and start the video now?

Speaker 2Excellent.

Speaker 2So thank you very much, Doctor Painina, for, for agreeing to talk to us about your experience. Once you introduce yourself, uh, tell people who you are and what you do for a living.

Speaker 3Yes, my name is Luis Kajina. I am an anesthesiologist. I work at Lake City Medical Center in Lake City, Florida, and, uh, I've been in this community since 1998, long time, uh, doing anesthesia, and, um, and, and I just retired a couple of months ago.

Speaker 2Congratulations. So, you know, as an anesthesiologist, what were your thoughts about having back Surgery under conscious sedation?

Speaker 3Well, um, it was kind of new to me. I, I, I knew about, uh, Spine surgeries under general anesthesia, but, um, under conscious sedation, it was kind of, uh, very, um, very new, um, uh, but

Speaker 3My son, who is also an anesthesiologist and, and works with, with you, recommended me to come to you because he knew that he, you were doing a fantastic job over there with all the patients and also um my

Speaker 3My, my expectations will be filled, you know, with the, with this type of Surgery.

Speaker 2So, you know, as an anesthesiologist, did you have any particular concerns about having general anesthesia or perhaps maybe some of the cognitive effects of general anesthesia?

Speaker 3Not really, um, not, not really for general anesthesia. I know that, um, as we grow older, you know, we are losing our cognitive capacities and, and, and we are having some limitations and general anesthesia, uh, could be more, uh, more deleterious, you know, than regional anesthesia or, uh, or, or more limited type of anesthetic, you know, for the, for, for certain surgeries.

Speaker 3So, but, um, that, that, that was my, my feeling, you know.

Speaker 3Mhm.

Speaker 2So, you know, as a patient, you know, now being on the Other side of the equation, and, and as a patient, did you have any particular thoughts or concerns about having Surgery under uh conscious sedation or regional anesthesia?

Speaker 3Well, I, at my age, I have had some endoscopies, you know, and I know, and, and being an anesthesiologist that is practicing uh that specialty, uh, I know that uh we can render the patient's unconscious.

Speaker 3But at the, at the point where we don't have to manipulate the airway and at the same time, the patients wake up sometimes, you know, not knowing anything about what had gone, was going during the, the procedures. So, um, I

Speaker 3I, I, I, I think, you know, the Spine Surgery is very intensive and, and I, I didn't know that, that you could do it, you know, under, under regional anesthesia or, or, or uh more limited, you know, it's, it's trying to avoid, you know, the general anesthetic.

Speaker 2So, you

Speaker 3know,

Speaker 2I know that you've performed spinals before and you've performed blocks, but being on the Other side, how, what was your experience like when you first had the block, the paraspinal block?

Speaker 3Uh,

Speaker 3It was something new. Uh, as a matter of fact, you know, uh, my son told me about the block, and, uh, and, and I, I was OK. I, I was ready. I, I was in the hands of good people. I knew, I trust you, and I knew that, that I was going to be all right, so I

Speaker 3I, I just rendered myself, you know, I was the patient. And uh at that point, you know, I was surprised, you know, the, the block was very simple to me as a patient, you know, I, I don't remember to have uh

Speaker 3To have suffered anything. I mean, uh, they gave me a little bit of Versed and, uh, and from that moment, you know, I was, uh, sitting up and, and, and, and the blood was, was excellent. As a matter of fact, you know, after Surgery, I mean, it was a little longer than 48 hours when I started feeling Pain.

Speaker 3I mean, some discomfort. That's what I mean.

Speaker 2And, and did you have to take any Pain medication after the Surgery?

Speaker 3I did when I started feeling the, the discomfort after Surgery. I, I took for 24 hours, I took the narcotics that I was prescribed, and that was it because the narcotics were so um

Speaker 3The, the, the side effect of constipation was what really bothered me as much as, as, as I said, you know, I cannot continue with this. Uh, and I, I started using my non-steroidal anti-inflammatory

Speaker 3drugs.

Speaker 2So, do you remember anything about your Surgery?

Speaker 3Uh,

Speaker 3In, in the middle of Surgery, I remember that I felt something and I said, I'm feeling something. I think I talked. I, I don't, uh, that's, that's the way I, the only thing that I remember. I was prone and I said that and immediately they gave me something else and then I don't remember anything else until I wake, I woke up in recovery.

Speaker 2Yeah, we did have a little bit of a conversation during your Surgery. I asked if you were experiencing any Pain and you said no, you just felt that you were having, that there was something going on but it wasn't painful.

Speaker 2OK. You know, as a, as a patient, you know, um,

Speaker 2You know, going into the, the Surgery and lying prone and having Surgery on your back and making the incision, I think patients are afraid they're gonna feel Pain or feel something. Did you feel any of that?

Speaker 3No, not at all. As a matter of fact, you know, I remember, uh, when they told me you, we're ready to go to the OR. I, I remember that I transferred myself from the stretcher to, to the table, and that was it. Uh.

Speaker 3I don't recall anything else after that except for the, that brief time when I, when I mentioned, you know, that, that I was feeling something and then I, I fell asleep.

Speaker 2That actually brings up a very, very good point in that with the Awake spine surgery, allow the patient to pos position themselves so they get very comfortable and the likelihood of getting pressure sores and, and areas of bruising actually are, is quite small because you're able to position yourself and get completely comfortable.

Speaker 2I do agree with

Speaker 2You know, one of the Other things that I, uh, patients, uh, uh, are worried about or have had Surgery in the past, experienced some significant side effects such as, uh, nausea and vomiting, uh, and constipation after Surgery, and I'm sure that you counsel your patients about that as well. Um, you know, how do you compare, uh, you know, the, the regional anesthesia with the sedation to general anesthesia vis a vis those types of, uh, complications or side effects, I should say.

Speaker 3Definitely a regional anesthesia and it's going to have less of those side effects. Uh, the, the

Speaker 3The, we cannot compare, you know, one to Other, you know. We see more um nausea, vomiting, you know, with, with general anesthesia than with regional anesthesia. So, um, I don't remember, I didn't have any of those. Uh, no nausea, no vomiting.

Speaker 3Uh, the Pain was tolerable, as I said, you know, for more than 48 hours, and also, um, the only, uh, side effect, you know, the constipation was more related to, to the pills, the narcotic pills that I started taking when I, when I was starting to feel Pain, uh, than anything else. I mean, I, I discontinued that and everything, so.

Speaker 2Yeah, I think it's important for the audience to know you, you had a two-level minimally invasive laminectomy and it's just part of your regional anesthesia, you've had um a paraspinal muscle block uh with a buppivicaine and, and exrolysosomal buppivicaine as well as intrathecal fentanyl. Um, and that lasted what, almost 48 hours, which gets you over the hump, which is what the, what the hope is.

Speaker 2And so I guess that the biggest question, you know, now having been through this, if you had to have back Surgery again, would you have it with regional anesthesia or would you want general anesthesia?

Speaker 3No, uh, regional anesthesia is perfect.

Speaker 3Regional speaks perfect. I, I, I have no complaints, no,

Speaker 3whatsoever.

Speaker 2Well, that's wonderful to hear. So, uh, for, um, there's gonna be some people who are not surgeons and not, uh, anesthesiologists who are gonna see this video. Um, if you had anything to say to a potential patient who is considering whether or not to have regional versus general anesthesia, what would you tell them?

Speaker 3I would recommend to have regional anesthesia. It's feasible, it's possible. It's, uh, it's, it's great, less uh chances of having uh um side effects, you know, and, and I think, uh, you can do the, the Surgery maybe ambulatory that way. So, um, cause I, I went, I went home the same day. Um, it's, it's another thing, you know, that is, it's a must, you know. So, um, uh, um, I would recommend regional anesthesia for, for your patients.

Speaker 3Having minimal.

Speaker 2Well, I, I think this is gonna be very valuable for both patients and for surgeons who are considering uh doing uh Surgery with regional anesthesia. And I can't thank you enough for sharing your experiences with us. I, I think this is very valuable. So thank you.

Speaker 3Thank you. I'm feeling great.

Speaker 2Uh, fantastic. I'm, I'm so glad you are.

Speaker 1We

Speaker 1are going to try to bring Doctor Huul in now and see if he can talk a little bit about his awake protocol.

Speaker 2Uh, hopefully you can hear me.

Speaker 1Yes, how are you?

Speaker 2Doing great. This is a fantastic, uh, course.

Speaker 1Thank you. Thank you for joining us from Cape Cod, but we have a better view than you do here in Tampa.

Speaker 2Mm, I don't know about that.

Speaker 2OK.

Speaker 1Well, thank you for that uh video. So, you've been doing endoscopic Surgery for how, how many years now?

Speaker 2So, I started endoscopic Surgery in 2015, but, you know, in retrospect, I actually I've been doing, I guess, awake spinal Surgery, if you can call it that, since 2003. And I started doing um kyphoplasties back in 2003, and, and all of them have always been under conscious sedation.

Speaker 2So, really, that's where, um, where I got started. And I think that's why it was so easy for us to transition, um, doing bigger surgeries or procedures because our anesthesiologists are already familiar with doing patients under conscious sedation in the prone position.

Speaker 2So, we actually, uh, it really was an easy buy-in for the, for the anesthesiologist. Um, and as you can hear from, uh, Doctor Kahina, and his son, you know, who I obviously younger, um, was very interested in providing regional anesthesia, was able to get a lot of the Other anesthesiologists involved, and, you know, they're, they've become some of our biggest advocates.

Speaker 1So when you went from doing these surgeries under general anesthesia to awake endoscopically, first of all, what was, what's your protocol? Do you use a spinal, epidural? Are you doing a block?

Speaker 2So, for my minimally invasive laminectomies, I typically just do um a spinal with uh intrathecal more uh intrathecal fentanyl.

Speaker 2And then for, and also the ESP blocks, and that's performed by anesthesia and they usually do that in the pre-op holding area.

Speaker 2For my, uh, MIS T lifts and my endo, endoscopic T-lifts, we do intrathecal dramorph to get a little bit longer, so I have a little bit more time to do the Surgery and a little bit longer time for Pain control, and also the erectrosinna blocks bilaterally. With the MIS laminectomies, I do the recrosine blocks on the side that I go in on.

Speaker 2For my endoscopic discectomies and foraminotomies, um, I typically don't perform, have, uh, I, I never have a spinal. I will perform the erectrospinal block myself utilizing fluoroscopy. Um, and, uh, the patients have conscious sedation with, um, remifentanyl and Presodex.

Speaker 2So, you know, the, the transition for me, you know, had been the familiarity of performing procedures under conscious sedation with kyphoplasty. And we would occasionally have someone who's just too ill to undergo an open procedure, and we would do an endoscopic laminectomy or a discectomy, I'm sorry, a minimally invasive laminectomy or discectomy under spinal and, and, and conscious sedation.

Speaker 2And really, the, the biggest change was in 2015 when we started doing the endoscopic Surgery. And to be honest, uh, I consider my endoscopic discectomies now to be not much more invasive than, uh, transaminal epidural because the access is essentially the same as a, a transaminal epidural.

Speaker 2And I can visualize the nerves. And, and one of the advantages of doing the Surgery under a local anesthetic is that I can actually ask the patient uh or and have my assistant perform a straight leg raise maneuver during Surgery. Um, and, and it, it, it never ceases to amaze me that I can have a, an 8 millimeter cannule in the epidural space, perform a straight leg raise maneuver and have the patient say their Pain is gone.

Speaker 2So I have this interactive feedback with the patient to let me know that my Surgery has been successful and also, as far as I'm concerned, on awake patients, the best neuro monitoring you can have.

Speaker 2So, I especially utilize that if I'm doing it, uh, endoscopic T lift, uh, under conscious sedation, placing the, uh, working cannulas into the epidural space or into the disc space, you know, I know right away if I'm irritating the nerve root, the exiting nerve root especially, because the patient will let me know.

Speaker 2And so I find that very valuable.

Speaker 1So it's safer. So at this point now, when you're doing a fusion, you're not using a spinal or epidural. You could do it with just a

Speaker 2block. No, no, I mean, I do the, if I'm doing a fusion, I will do a spinal, but it, it, there's no Bpivocaine in the spinal, it's just a narcotic, um.

Speaker 2You know, one of the things that our anesthesiologists have noted is that the amount of fluid that they've had to give people to maintain their blood pressure dropped significantly. And when you talk about doing an elderly patient or not only do you have the cognitive effects of general anesthesia, but a lot of times they get overloaded with fluid. Let's say you're somebody with some cardiac issues and you volume overload them, um, you can have some significant, uh, postoperative complications. And what we're finding is, is that

Speaker 2Um, the requirement for

Speaker 2Blood pressure medications, um, and volume to maintain their blood pressure basically goes away.

Speaker 2And um, it's been, it's one of the things that the anesthesiologists have told me that they've noticed, which I, I think is fairly significant. We have such an elderly population that, um, you know, anything that can push these frail patients over the edge, if we can avoid them, the patients just have better outcomes.

Speaker 1I think that's gonna be a great discussion to have during the Q&A with uh Doctor Bullock that, it's fascinating. So the question is now, when are you gonna start doing awake fromomotomies in your office?

Speaker 2Yeah, yeah. Probably next week.

Speaker 1After taking this course.

Speaker 1Great. That, that's absolutely amazing. Thank you very much. Thanks for joining us. Thanks, thanks for making my video. It's absolutely amazing. I think that the endoscopic guys are really pushing the edge as it is from a surgical point of view, but coupling that with their change in anesthesia technique is almost like a, the fact that an endoscopic procedure is almost like an Injection is incredible.

Speaker 1That's, it's really pushing the edge. So thank you very much.