Awake XLIF

Speaker 1So this is actually gonna be really cool, this next really talk. Um, can we get, can we loop in uh Georgio's please, Justin?

Speaker 1OK.

Speaker 1So, this is a really interesting story. So, Georgios Bacolois is a, is a Spine surgeon in Italy. He's got a practice in both Milan as well as Rome. And as you know, Italy got crushed during COVID. And this, the hospitals just weren't allowing any surgeons to do any kind of Surgery. Um, this is where Innovation really comes out. And what had happened during that time was, um, I think it was more Rome than Milan, that the surgeon, the anesthesiologist told Giorgios that

Speaker 1Uh, will allow you to do Outpatient Surgery. Now, Giorgios, you'll see is a master at doing the XLft procedure. And he basically figured out how he can apply the awake protocol to the XLF procedure so that he could do Surgery during the whole COVID period. And I'm really excited to hear his talk today. He's coming to us from Milan or Rome?

Speaker 2I'm Rome. Rome,

Speaker 1he's speaking to us from Rome right now. And he's gonna give us his experience. Thank you. Go ahead, George. Thank you for joining us.

Speaker 2It's a great pleasure for me being with you and uh I really like to

Speaker 2To say a great hello from Rome. As you mentioned, uh, the whole thing started as a matter of fact, um, more than 3 or 4 years before the, the COVID Pandemic, we had already had some experience on spinals here in Italy and um it has been, uh, extremely, um, you know, the, the COOVID here in Italy as we were the first place where the whole thing happened.

Speaker 2Uh, in the western, um, regions, we had to do something that they call the, the fast prototyping, do the best that you can do. So. Can you hear me

Speaker 1now? Now, we could, thank you.

Speaker 2We all know that the problem, the most important aim of ours is, uh, firstly to decompress.

Speaker 2Necessary to correct, you can go on. You know, the literature, you have already talked about it. There are uh some uh early papers from the Miami Advance, please, and then from uh the San Francisco one and you can go on.

Speaker 2So, uh, the present study was to evaluate, uh, at a minimum 2 years follow up our complication rates and results in a, in a single surgeon practice. Go on. Advance, please. So this is, uh, the whole series of, uh, our 1st 155 patients, and, uh, uh, there were 72 cases of stenosis and 30 cases for denitis bondi. The remaining one was a discogenic instability. Advance, please.

Speaker 2So for level fuse, the period is from 14, 2014 to 2020. Uh, for level fuse, we were able to do up to 5 levels with 43 cases were uh um associated with the decompression, 15 cases there were extreme lateral uh interbody fusion. Go next, please.

Speaker 2So for what concerns our, our anesthesiologic protocol, we currently, uh according to Angelo Mazzarino, which is the chief anesthesiologist, as I was saying, he had a, uh, he has an extremely um um wide experience in the so-called obstetric uh walking anesthesia here in Italy.

Speaker 2So he um um put, put down this kind of protocol. He did a, an epi he does an epidural single-shot uh narrowpin with a 0.7% of 75 to 111 mg.

Speaker 2And uh 1 to 2 mg of morphine. I'm going to, I will not go inside the whole thing because it's a matter of my anesthesiologist. The things I do that that we try to uh put inside in my practice, this kind of thing, and uh we have already uh postulated the post-op with the perioperative uh protocol, as you can see here, we don't use a certain stage of the PCAs. Next, please.

Speaker 2And our results, you know, this is not my practice both in Rome and Milan or Bergamo. It's not an ambulatory center, so for us having more or less 2.8 days of hospital stay is already a great result. We don't have to send the patient the same day out. We have no transfusions, practically no any kind of blood loss. Our operative time, which has

Speaker 2change, there's not such a change in the operative skin to skin has a great change for the whole thing from the time that the patient comes to the operating room than when he goes or she goes to the recovery room, and we all already had our patients stand up in the next day and in the last cases, mainly with a single shot.

Speaker 2Protocol, we have had the possibility to make the stand 3 to 4 hours later. Next please.

Speaker 2So, for one consent complications, we already had um assessed that uh we had more or less 5 revision surgeries for adscent segment disease and um in 2 cases, we had to perform an implant uh revision for um pseudo arthrosis. The amelioration of in the ODI was the one seen already, not in the awake Spine. Next please.

Speaker 2So, a couple of cases. Uh, so as to talk about the laterals. The lateral Surgery, which is an anterior retroperitoneal Approach, is not a new one for us. And as a matter of fact, the team building as the previous.

Speaker 2Um, speaker said is the whole thing. The only thing that changes, is the fact that the person is, is, uh, awake. You can speak with him, you have, uh, kind of change in your, uh, mentality, how to do the whole thing and how your team that has already had the experience in the act, brings it in, in, in, in a, in a, in a different way. Next please.

Speaker 2So this is a mild scoli, uh, already had a couple of uh previous microdiscectomies. Uh, the patient's awake, he's draped in the same way. We don't jackknife, we do a slight, um, bending. As you can see, there is a monitoring, um, instrument because in the first case, I was not so, so, you know, so, um, uh, easy with myself without monitoring. Next, please.

Speaker 2Then I don't know if you can hear next. You can push the button, if you can see the video, and I don't know if you hear, but as you can see, we can see the video is a practically the patient do the monitoring. I'm sorry, we can see the video. OK, so you see the patient in the beginning of the operation that we can see how he moves. The next one is once I have already done with the cage. Now the camera is going to.

Speaker 2And you know, the, the procedure is the same. It doesn't really matter. You do the same steps. It's a matter of uh the whole um team that follows you, and as you can see, it takes more or less 20 minutes from skin to skin to do the whole thing in our hands. It doesn't matter if you do it in the 30 minutes. The most important thing is the time that your dilator is open. Next, please.

Speaker 2And then in the same position, if you push the button, you can start with the uh um with the video. Uh we put inside the screws in the same position, which is a single one, and we can also see during inserting the screws to have an immediate, you know, neuro monitoring, if you can make call it like that. I don't know if you see in the back of the screen, there is a monitoring, there's a Nuva map, we have a lot of noise.

Speaker 2The noise is probably due to the fact that the person is awake, and when he moves, you see the whole thing going out, you know, in I, I tried it in the 1st 2 or 3 cases, and when I do a 34, I don't anymore use any monitoring. 45, I'm not so, um, I don't feel safe, so I, I still use the monitoring, even if the patient is awake, which is a trigger to EMDs. Next, please.

Speaker 2The most important thing is that if you can see, and you all know that you do the wakes, push the button, please, so that you can go on with the video. The patient writes, you know, once he, he, he uh turns from the table, you have an immediate um feedback of your, of his monitoring uh with his neurological um exam. We did um a regular.

Speaker 2indirect decompression. I didn't do any laminectomy. laminectomy for me is something to avoid too. Next, please, you can go on with the video, and then this is the same patient less than 4 hours later on the ward. He has his um um.

Speaker 2How do you call it, when you, you put, you know, the intravenous thing. It's not a PCA. He walks around the world and then uh we still have, you can go on, we still have to uh keep the person, push the button, please, uh, the pes inside the, um, in the ward for two days here in Italy because

Speaker 2We are working in a Private practice, but it is um reimbursed from the state, and we need to do a couple of days after the Surgery. As you already mentioned, this is Angelo and me that we are putting the patient in, uh, in the lateral decuper position, but in, as a matter of fact, she's putting herself alone. We have no monitoring. Um, the whole workflow is extremely, uh, next, please, is extremely, um, um.

Speaker 2You know, really quick, and I don't know if you can hear the, the, the voice of the patient because sometimes they are not so comfortable, so I must stop when I'm, you know, hammering in her lateral abdomen. I stop, I talk with her. I just try to, you know, make her feel more easy and more comfortable as I am inserting my cage.

Speaker 2And uh it's only a matter of a different way of doing the Surgery for yourself, and also for your team. They know the Surgery, this is the main thing, but it's a new way of having a feedback also from your patient, and not only the monitoring, but how she feels, or how she feels. Next, please.

Speaker 2And once the Surgery

Speaker 2If you may call it the procedure, the cage is inside, um, you can really have, uh, uh, um, uh, um, an immediate, immediate, um, feedback from your patient how the 45 or the 3-4 root is gone, and if you have had something went wrong in.

Speaker 2In, in your plexus, which is the main enemy in this kind of Surgery. Next, please. And, you know, if uh you can, OK, then, as you said, you, you have a hug, quite a hug with your face, and then you turn it on her, on her um bed and uh she has been

Speaker 2Bedridden for a complete cauda syndrome for 2 weeks, and in less than 4 hours, she can, you know, stand by herself, and there are no miracles. It's the only thing that, uh, you know, it's everything really more fast. She stayed with us in the rehab wards for a couple of weeks so as to gain her gait.

Speaker 2Improvement, but it was extremely, um, not only encouraging, but also surprising for us to see a patient that was 2, for 2 weeks in her bed, walking and standing less than 4 hours after this kind of procedure. One of the most important things is not the fact that you are doing laterals or tulips or pilifts or Robotics or whatever you are. These are only um kind of um instruments. The most important thing, as we say back at Bologna, where I studied.

Speaker 2Is the fact that we call it the 30 rule, which means that you must be simple.

Speaker 2And uh this is a kind of teambuilding. Your teambuilding brings you to the Efficiency, and the Efficiency in your operating room and in, on your staff gives you the reproducibility. The whole thing, in my mind.

Speaker 2We can also make affordable, so, to have the inexpensive way of doing the things. In Italy, we do, we are still not so, um, you know, uh uh attached from this kind of thing, from er expenses, but it's gonna be the future. I know that in the US you are so sensible on that, but um I definitely, definitely believe that the COVID Pandemic gave the, the, the, you know, the push.

Speaker 2So us and uh gave us the, the, the urge to go on an awake, more awake procedures. And uh it's something that has to do with our mentality, as Cern said, and the new kinds of technologies.

Speaker 2Can enable us, they're not only enabling, can enable us to step up and, you know, to foster our recoveries and to extremely lessen our, our, our, the whole thing inside the hospital because it's a matter of experience of the patient. It's not only about drugs or opioid use, it's the experience. So, and so, as you know, to, to, um, my colleagues, I believe also in the States.

Speaker 2If you go to a patient and say that you must have a, a Knee arthroplasty or a Knee arthroscopy, the patient says, when?

Speaker 2We must have the same thing. If you have a spinal fusion, whether it is a TL leaf or ALF, ALIF it's a little bit difficult, but a PIL, we must arrive to a scenario where the person says, not, mm, I'm not so interested, but he's gonna say, when I'm going to have it, and the awake Spine thing is probably the way. Thank you so much. I'm so sorry about the technical problem.

Speaker 1No, no, thank you. That was a, that was really an incredible presentation and, and thank you, and it, I think it just goes back to, um, a lot of times people ask.

Speaker 1I say that I can't do this, but you've basically said, why can't we do this? The fact that we could do an awake XF is, why can't we do this? But my question to you is, um, that in your region, in your country, how have you been able to overcome sort of the pushback?

Speaker 1That people would naturally expect when you're trying something new.

Speaker 2You know, we have been obliged. That's something that, you know, history already taught us that when you, where, where there is a need, there is a way. When we had the problem of, uh, of the COVID, um, at the beginning, everybody said that we had to avoid general anesthesia because everybody believed that the, the, the, the general anesthesia put in a great uh um risk anesthesiologic team.

Speaker 2So we were trying to find out how to overcome that and how to go on with our surgical um um portfolio. And so we had the possibility, we were one of the, of uh the few clinics at Rome that we were uh allowed to go on with uh our regular, um, our regular uh um surgical uh program. That was the whole thing.

Speaker 2Then we had the right people with the right team, and um

Speaker 2Patients, you know, were not so um easy to overcome the thing that everything was done awake, and the whole thing is that you get and you talk with them, and you try to find a way that uh you are, uh, you know, not only behind them or outside them, but you are with them. It's a matter of um talking and explain what you're doing, and you can do it also during the procedure, you know, that's the amazing thing.

Speaker 1Yeah, no, clearly, you're, you're making movements cause like, I know that I've gotten a lot of phone calls from uh surgeons in the Mediterranean areas, Spain and Portugal who have heard about your awake techniques. So, thank you very much, Georgia. Sorry for all the technical difficulties, but thank you very much for joining us today. That was a beautiful presentation.

Speaker 2Thank you. Thank you so much indeed. Thank you.