Q&A Session 1

Speaker 1The first question is, what's the Learning curve for all these blocks? I know what I've gone through.

Speaker 1Personally, as well as with my team. But can you tell us a little bit about what the Learning curve is? How many cases, how long does it take you to do the block? What are the challenges in overcoming the Learning curve?

Speaker 2Uh, the Learning curve for these blocks is actually not very, uh, very long. It's, it's, it's actually fairly quick to get, uh, people proficient at doing these blocks, and I think the, the reason is because

Speaker 2While you're targeting a specific area, you're, you're actually targeting kind of a broad area, uh, when you do, um, you know, the T-lip block or, or whether you do the, the erector Spine block. That those planes are fairly large, um, and especially with the rector Spine, you know, being able to see the needle come down in contact, uh, is, is fairly easy to do. I think the challenge comes in if you haven't picked up an Ultrasound before.

Speaker 2Um, learning the Ultrasound and how to move the Ultrasound, and how to get the needle in view is the biggest Learning curve. The actual blocks themselves are not.

Speaker 2So figuring out how to use the Ultrasound and how to see your needle is really kind of gonna be the time-intensive part. Um.

Speaker 2There are, uh, modalities to be able to practice that. There are trainers, Blue Phantoms. There's a trainer that we have back here that we're going to use later, um, so people can see how you can effectively learn how to use the Ultrasound. Once you learn how to use the Ultrasound, the blocks are easy. Hm, interesting. I would say maybe to get really good results, um, 8 to 10 cases.

Speaker 1OK, that's good to know. That's not a major hurdle.

Speaker 1Um, Kingsley, from your perspective and, in your team, tell us a little bit more about, um,

Speaker 1What was your reaction when you first started doing this? I mean, did anyone say you're crazy? And if they did, how'd you overcome that?

Speaker 3Yeah, you know, um, when we first started discussing this, I, I think, um, you know, for, you know, again, I think you have to have a very frank discussion with your team, you know, I think

Speaker 3The biggest hurdle I think is initially uh convincing um uh the anesthesia group sometimes that this is safe and this is something that, that, that would be OK.

Speaker 3Um, for me, I think that was really the biggest thing that we had to overcome, you know, we, we met frequently, talked about both our concerns, the, the concerns that they had, the concerns that I had, um, how we're gonna position the patient, what do we do if something goes unexpectedly. I mean, I think once we had a protocol in place of what we wanted to do and how we're gonna address things that come up.

Speaker 3Um, everybody felt more comfortable. I, I think initially everybody was a little bit hesitant, uh, but nowadays it's just another case, right? I it's not anything that anyone is really resistant to.

Speaker 1Yeah, it was really interesting because I got a phone call, maybe 6 months ago from a surgeon in Chicago, who has said, um, I need to, how do you do this awake fusion thing? I said, just randomly. I mean, I knew him perfectly. And I said, why? I said, because this patient approached me and said, I want you to do my fusion Surgery awake. Can you do it? If not, I'm gonna go to the next surgeon.

Speaker 1And over the phone, we had to educate him. And so by patient demand, right, by patient demand, he was basically asking and he was forced to learn how to do it. And actually, he's doing really well now in Chicago, doing awake fusion. But the Other question that comes up, this is a question that came from the chat boxes, what do you do for neuromonitoring during these cases?

Speaker 3Uh, I typically don't do neuro monitoring during these cases. I, I don't see, uh, a need to for these patients, um, for even my, uh, TLLft on during, during general anesthetic. I, I don't typically do monitoring for

Speaker 1those patients. Has that been your experience as well, Mike? So no, you don't need to do, OK, cause they, it is, I mean, I think the evidence is pretty clear that you plus or minus whether or not you need to do neuro monitoring during an awake TLLFft. Ernest, what's your thought on that?

Speaker 4When I'm doing an epidural block, I don't, I don't monitor because it's, it's not a very dense block. Um, when I'm doing a spinal block, um, we'll just do trigger EMGs. That's it, you know, we'll just stem the screws, make sure they, they stem out to 20. Um, uh, I, I, I, I, I think that there is an added cost to neurological neuromonitoring both in setup time.

Speaker 4And also in a direct cost to the pair. Um, and so, you know, I, I try to avoid it, but in, in my community, uh, we just do a trigger EMG. It's just, it's just kind of part of the workflow. Um, I had another question though, um, for, for, you know, Doctor Bullock and, uh, Kingsley and yourself. Where do you do the block? Do you, the controversy, do you do it in the OR or you do it in prep and hold? Where do you do the block?

Speaker 2All of our blocks are done out in pre-op. Um, the erectros spinal blocks are definitely done out in pre-op. That's the easiest way for us to do it. The surgeon comes, sees the patient, uh, we see the patient, get all the paperwork in order, do the blocks out there, um, and then the spinal is kind of, uh, up to the anesthesiologist if they want to do it in the room or if they want to do it out in pre-op as well.

Speaker 2Um, if we're doing a spinal, generally we do it out in pre-op, um, but it depends on, you know, first case starts and turnover time and, you know, kind of time limited stuff. We may move him to the operating room to do it. In general, we do the blocks and the spinal out in pre-op.

Speaker 3Yeah, so for the uh blocks we initially started doing them at the end of the case, uh, mainly because I was concerned that I would get into that fluid and, uh, fill my surgical space with it. Uh, but we've transitioned to doing them in pre-op, uh, for the spineal for the intrathecal spinal itself, um, I attempt to have them just do that in the operating room.

Speaker 3It takes them about 5 minutes to do and the patient is ready in a position and I also enjoy having the patient position themselves, um, because like, as you mentioned earlier, they're really gonna put themselves in a position that is most comfortable for them, uh, so we're not having to adjust them.

Speaker 1Yeah, so our workflow is that we bring them in the operating room and then the clock starts. So we have them do the spinal anesthesia and then the patient positions themselves prone. And then while the patient's getting themselves comfortable, I'm getting ready to do the block. So the patient is prone and then we're doing the block. It's actually kind of nice because while we're doing the block, the anesthesiologist is still getting set up. So I don't, I don't really waste any time by having the anesthesia do things related to the head while I'm doing the block.

Speaker 2So I really like the way that you all Approach this with the spinal in the room and having the patient position themselves, and that's something that I'm gonna take back and see that if we can do this. Um, there's an issue with, uh, um, blocks for blocks and spinals, uh, in terms of anesthesia billing, and this is just something that I'll briefly touch on, but once we do the spinal, that's our surgical anesthetic. If we do blocks beyond that, that's part of our anesthesia time. If we do the blocks before the spinal, it's not part of our, our anesthesia time.

Speaker 2We can actually build for post-op Pain control. So, just kind of a, a, a small issue, but that's sometimes why we do the blocks beforehand, um, and then do the, the spinal afterwards. But I really like the way that you guys Approach doing the spinal in the room and having the patient position themselves.

Speaker 1Yeah, that, that raises a really good question. So, um, as our awake Spine course evolves, we'll probably have a branch off point about the, the Business aspect of it, because the coding part of it is actually kind of interesting. Uh, two parts of it. One is that, um, we've had mixed results in terms of getting reimbursed for the block.

Speaker 1If I do it versus the anesthesiologists do it, there's been mixed results. I could tell you on both ways that there's times where I've gotten reimbursed, I've not gotten reimbursed, and it is all just gotten reversed, he's not gotten reversed. So we've seen it both ways. So that's, and there is a code that um it, it totally matches up that you can use for the blocks that works out really well.

Speaker 1The Other part, which is interesting, and again, it's not in the purview of this course is billing from the hospital perspective, because hospitals will start losing a lot of money if you don't build these cases properly, because it's an Outpatient Surgery. And at some later point, perhaps we'll think about having like a billing, a whole billing aspect to this course as well. But that raises a good point as well.

Speaker 4I, I just have another comment for uh Doctor Bullock. You, you did talk about cervical a little bit. You mentioned two blocks, um, the superficial cervical plexus block. I do that on all my arthroplasties and ACDFs. Of course, they're under general, but it's an adjunct for Postoperative Pain control. Um, I don't, I don't bill for it. I just mentioned it in my note. It, it's very quick. It's very easy. I see the uh sterocleidomastoid, inject 10 cc's.

Speaker 4The posterior um ESP, um, we, we have not done that. I have some concerns about a phrenic nerve palsy. I don't know if you've seen that or, or, or seen it or heard that described in the literature, but I, I think you can bag, bag the phrenic nerve if, if you do the ESP in the cervical Spine.

Speaker 2Yeah, definitely, I agree. I think that you can. Um, I haven't, we, we don't do those at all. Um, it was in the literature that I actually saw these blocks, and there's there, um, I didn't read about specific phrenic nerve, um, palsies, but I, I can imagine that it would happen.

Speaker 1So we, um, we've tried the, the MCP block multiple times now for posterior cervical Surgery. It's a, it's amazing, actually. Um, I don't have enough data to be able to present it beyond just saying it's anecdotal, but I can tell you that when we're using, um, small doses of Experil for the posterior cervical, it's a game changer.

Speaker 1Um, and we've tried to do it for the ACDFs. It, it's hard because if these patients are in a lot of Pain and if you're injecting their neck, it can rev up the system a little bit more. So we gotta be a little bit careful, but anecdotally, it works really well.

Speaker 2Yeah, and I think the Other thing that I would say is if you're using uh small volumes and the spread, if it's similar to a rector Spine or to the T-lip blocks, is going to stay more posterior and not actually affect the, the ventral rami, then I think you're safer.

Speaker 2In terms of, uh, keeping the, the phrenic nerve uh viable.

Speaker 1Interesting.

Speaker 1Good. So, if we can just, we'll take a five-minute break, um, that we have, uh, drinks and then food over here too. And then we'll come back and I'm really excited for this next segment where we're gonna start talking about the application of awake Protocols for all the different types of Surgery. OK? Thank you.