Why Awake Spine Surgery?

Where patients are delayed in their recovery to a spinal anesthetic. Um, you know, this is not a new concept. This is something that has been well adapted and found to be safe in all the specialties, uh, in neurology and pediatrics and, and, uh, uh, OBGYN, uh, they, they constantly are using, uh, spinal and regional anesthes.

Anesthetic to achieve the same things that they were doing under the general anesthetic. Now, if you do a a search on PubMed and just type in uh uh Spine Surgery under a uh uh uh spinal anesthetic, you can see that again has been a lot of literature over the last few years that has drastically increased.

If you look at awake Spine fusion, um, again you see that the data there is not as much, but is, is significantly increased over the last few years, and some of the names in this room are are really the leaders in pushing this, uh, and showing the benefits of this.

So there's been a lot of publications on this, you know, uh, looking at the benefits, both retrospective, prospective, um, looking at awake and the benefits of this, and so some of, these are some of the data that's really have been out there, and I'm just gonna dig into some of that and show you guys some of the, what the data shows out there.

So the benefits of Awake spine surgery really ultimately comes down to, and this is what a lot of these papers is found as well as overall decreased OR time in patients, uh, less post-op um um opioid use, uh, decreased time to emergence, increased patient satisfaction, decreased time to ambulation, or an overall decreased cost, which all makes sense, right? We're doing the same thing using uh less uh equipment, um, and less, uh, anesthetic to achieve the same goals.

Well, I think this is one of my favorite um article. This was a randomized, uh, uh, uh, paper that came out in 2011 by Atari.

In their group and what they did was they randomized about 35 patients into a general versus Awake spine surgery and you can see here that they found really not only decrease in intraoperative measures like the patient's blood pressure, um, but overall decrease in, uh, blood loss, uh, patient satisfaction was increased compared to a general anesthetic.

Uh, patient satisfaction and surgeon satisfaction will increase, and overall they also noticed a decrease in postoperative anesthetic, uh, opioid use as well in these patients.

I think this is a very important paper to uh to really take a look at as well and looking at awake versus a general anesthetic, anesthetic, especially when we're thinking about this aging population group. Uh, when you compare overall a general anesthetic to a spinal anesthetic, what you notice is that there's a significant increase in the amount of medications that are required just to put a patient on a general anesthetic versus a spinal anesthetic.

And, you know, the, the trend as you look to the right is that even though we are supposedly getting better at what we do, we're having to give an increasing amount of medications to patients.

Have when they are undergoing a general anesthetic where that trend is really decreasing when patients are going, undergoing a spinal anesthetic. I think this is very important to, to really sink into to people because as I mentioned earlier, you know, we have this aging populations that really want to address their Pain but get back to their life as soon as possible. Uh, when I got interested in awake, um, Surgery, the really the thing that was the motivator for me was seeing patients post-op after.

undergone a uh Surgery under a general anesthetic. While the patient's Pain was better, while they were doing great from that standpoint, for months on end, what patients really came in with was the fatigue. So I have patients that were just coming in, you know, doc, I'm feeling great, but I just continue to have this lingering fatigue that's just is not getting better, and some of that is, I think is a combination of this medication and the general anesthetic that patients are, are getting, um, when they undergo a general anesthetic.

So I'm gonna talk a little bit about some of what we found in our experience at Mayo Clinic. This is a, uh, uh, uh, a paper that we published and uh recently. We looked at 40 patients undergoing either a TLL by general anesthetic.

Of, uh, a spinal anesthetic and so these are some of the data points that we collected in these patients. What we found was similar to what has been found in some of the Other papers, uh, significant decrease in our overall OR time and, uh, as well as our operating time.

Um, and the time to leave the operating room was significantly lower as well, right? There's really no emer emergence that needs to happen. Once the patient's flipped back to the supine position, the patient is ready to leave the room and can walk right out, uh, and can be rolled right out of the room. Um, what we also found again, so decrease in the OR time, I think the interesting thing here as well is that when you look at the spinal anesthetic versus a general anesthetic, the variability in time is really

Small, right? Uh, so, and I think, you know, it's hard to explain why this is, but, um, I think what you find is that because you're doing this with, uh, spinal anesthetic, all your teams are really in tune to this and trying to make sure that things are moving smoothly. And so, you, you are able to accomplish the same thing with uh decreased in variability in time and a significantly less time, uh, for patients as well.

So what we also found is looking at both the mean and the max uh Pain score in these patients, um, well, again, we found that the mean and max uh score in these patients is significantly decreased, and both these patients are using the same amount of opioid equivalent, uh, but those undergoing a spinal anesthetic has, uh, have significantly decreased in the overall Pain.

Uh, for us, what we also found was the time to ambulation in these patients was significantly decreased compared to patients undergoing a, uh, general anesthetic. All of our patients, well, you know, when we initially started this, we were admitting patients, but all of our patients now are able to go home the same day.

With great Pain control, uh, I was speaking with someone earlier and the fact that, you know, there, there is a Patient Selection that, that needs to happen with this, but overall, um, this is, uh, this is really a, a technique that can be used in most patients.

The Other paper I'm gonna discuss here is a, uh, is one of our prospective studies that we've done. We've obviously looked at the intraoperative benefit, the decreased in over time, patient satisfaction in regards to Pain score, but one of the things that I really was interested in is, one, are we affecting patients long term in, in their overall fatigue and also mental status and their ability to return to their normal activity.

So what we did in this prospective study was that we collected 55 patients. Uh, ultimately, uh, 5 patients decided on not undergoing Surgery. Uh, you could see the very, you could see the demographic in both these patient groups, and they're very similar in nature. There's really not a significant difference between the two groups of patients.

What we found for these patients, we wanted to look at their fatigue score. Uh, I don't have the preoperative fatigue on, up on this, but they were essentially normal, uh, about equal on both these group of patients. But what we found in this group, this is about a month out from Surgery.

The post-operative fatigue in the patients undergoing a spinal anesthetic is significantly decreased compared to patients undergoing a general anesthetic. We also found the same thing in overall postoperative physical, uh, activity, uh, although we did not see any difference in the overall mental score for these patients. And that's not unusual because the, the

Uh, scores that we used for measuring, uh, mental status change in these patients was a, uh, uh, the, uh, mental mini mental, uh, exam, um, and that's really meant to pick up on large differences, right? And so I think we need to do more of a robust study to really notice that difference, uh, but that's something that we are working at and looking at, uh, for the future.

So I think as I mentioned earlier, when you're doing, when you're considering changing to awake, there are a Patient Selection that, that needs to be uh considered and that's gonna be discussed later on but uh I'm just gonna uh briefly kind of mention this. Obviously, you know, you got

You have to think about, you know, the, the different parameters for different patients, what kind of anesthetic you, you wanna use, positioning for these patients, how you're gonna manage the airways, and we have a protocol that, you know, with our anesthesia group, we've really put together. So I'm gonna just quickly go over, uh, one of our first patients that we did, um, and

You know, just show a little bit of how we manage these patients. So this particular patient was a 66 year old female. Uh, she had had a previous laminectomy for synovial cyst resection. Uh, she had done well for some time but started having radicular Pain again, as well as back Pain. She was intact neurologically, uh, but, um, you could see her scans here and, um, this is how she presented. She had failed conservative management, so she initially came in and

You know, as Lo uh mentioned earlier, uh, patients are really, uh, I think, more in tune to the effects of a general anesthetic. And this was a particular patient that came in requesting to have Surgery under a spinal anesthetic right as we were getting our program going.

So I'm gonna just play this video, uh, how do I do that.

I just kind of walks you through um the way we handle our patients. So, you know, our anesthesia group, uh, they go ahead and do the uh intrathecal block.

The patient is placed in the OK. You don't have to put the sound prior to the patient feeling the full effect and the beauty of this is that the patient really helps physicians themselves, right? So, uh, as the block is starting to set in, the patient can help position themselves. They can put themselves in a position, uh, where they are most comfortable. I use a horseshoe with the head, uh, uh, forms so that patients can, uh, you know, it's something familiar. Most patients have undergone a massage, so it's something similar.

Something that they're used to. They are able to listen to their headphones and constantly headphones, um, you know, uh, when we first started this, we were doing this a lot under a, uh, with the arm. Um, nowadays we're using more of the, uh, robot, um, as, uh, uh, Braxton is going to discuss, uh, later on during this, uh, skin incision was made in the planned location and the fascia was opened, so you can see here.

Making our incision or screws placing our screws. The patient is wide awake during this, this whole process, and we, we will, we have our anesthesia group, uh, just periodically check on the patient, make sure they're comfortable, make sure they don't need to shift. Once I placed the screw, it really, if a patient needs to, um, adjust, I let them go ahead and do that, and the disc uh, we go ahead and do our facetectomy. This space was opened with a 15 blade. A shift was used to prepare the prep our disc space, and the disc was removed.

Periodically, the anesthesia team checks on. You can see here the patient is awake. She's doing well. She's, she's talking to anestheeded, but our trial our cage was expanded up to a 10. The disc space was then filled with autographed and allografted, and antibody cage with 10 degree low doses was placed.

And good placement was confirmed with intraoperative and we can go ahead and take a, a scan, and this is uh post-operative scan towel onto the pedicle screwsper scan and 40 millimeter rods were secured in place by images of us scan and you can see here the patient is wide awake. Uh, patients typically are just asking, uh.

Some questions, how are things going back there? And they're, but they're very comfortable, you know, um, and they are really, uh, able to be as awake or just most patients end up falling asleep while you're doing this. As you can see, as soon as the Surgery is done, the patient's able to go right back to the supine position and is ready to, uh, leave the operating room. The patient is taken to the operating room.

With the end how do I, here we go. So this is a post-op scan on this patient. Patient did very well after Surgery, really no issues, um, and, and, you know, it's been mentioned earlier, this is something that really cannot happen without really a multidisciplinary Approach. Uh, our anesthesia team and

You know, our chair, my chairman has been really instrumental. Gaetano, who is going to be one of our, uh, new residents, has been instrumental in not only collecting this data, but also helping to push this program forward. Um, with that said, I'm gonna open it up for any questions. Yeah.