---
title: 'Awake Robotic Spine Surgery'
type: 'lesson'
url: 'https://doc.social/courses/awake-spine-hybrid-course/awake-robotic-spine-surgery'
course: 'Awake Spine Hybrid Course'
course_url: 'https://doc.social/courses/awake-spine-hybrid-course'
position: '8 of 15'
author: 'Alok Sharan, MD MHCDS'
transcript: 'yes'
---

# Awake Robotic Spine Surgery

## Summary

_This lesson is a recording without a written summary._

## Transcript

4,502 words · 24 min · 2 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:07] Speaker 1: So, I'm really honored next to introduce Doctor Braxton. Doctor Braxton is in Vail, Colorado, who's really cutting edge. I mean, what we're gonna see today with the integration of the robots, um, is, is really gonna be amazing. I'm really excited to introduce him and hear about how he's been able to do awake Robotic Surgery in the ambulatory Surgery Center.
[0:29] Speaker 2: All right, so let's, let's get to it.
[0:34] Speaker 2: So these are my relevant uh disclosures. I think the most important disclosure that I have is that I'm a physician owned owner in a Surgery center.
[0:42] Speaker 2: So we're gonna talk a little bit about the rationale of why considering uh adding, um, some enabling Technology to a place like a Surgery center, identify which, um, patients are optimal. You've heard a lot of that before. We've discussed a lot of, uh, a, a lot about ARAS, Enhanced Recovery after anesthesia, and, and, uh, anesthetic Protocols. I'll show you what we do in Vail, um.
[1:07] Speaker 2: That's a little bit different place. It's a unique environment. We operate around 8250 ft above sea, uh, sea level, so everybody's relatively hypoxic to start with. Uh, learn about the role of enabling, uh, Technology. I'm gonna talk about REMy with Leiden cider and, um, expandable innerbody fusion devices if time allows.
[1:25] Speaker 2: OK, so let's just start with the case. This is somebody that shows up in everybody's office, 65 year old male with uh uh spondylosthesis. He's really tight. He's got back and leg Pain. It's lifestyle limiting. So this is, this is not a um uh unusual case, and this is a, a great case for the Surgery center, but we'll get back to that. So,
[1:47] Speaker 2: Uh, no, uh, institution can possibly survive if it needs geniuses or Supermen to manage it. That's Peter Drucker, kind of the founder of Modern Management. Uh, I'll look and I both took some time to get some Business training before, um, getting to our Practices. And I, I bring that up because this is something.
[2:05] Speaker 2: that needs to be reproducible, have predictable outcomes. And I think sometimes using enabling Technology can help make it a little bit more predictable, OK? We all are, you know, could throw a basketball and get into a hoop, but if you have a tool or training tool, I think you're gonna get more, uh, more and more, um, better accuracy.
[2:23] Speaker 2: Better times and more predictability. And so robots have played a role. A lot of them are actually robots. They're navigated drill guides for the most part, but they've gone through this evolution. And the, the uh Mazer was really the first um robot before it was, you know, acquired by Medtronic to be really.
[2:41] Speaker 2: Used for Spine Surgery, uh, shortly after we've seen another evolution, we, on Globus came out with their system. It's very similar. It's, it's got the same northern digital components, the same wall AI camera, but again, instead of being table mounted, it's, it's, it's, it's on its own independent platform. And then, uh, we'll talk a little bit about Remy and why, why is that the next generation? What makes that different?
[3:07] Speaker 2: Um,
[3:08] Speaker 2: Uh, with any adoption of new Technology, you have, you have MAvens, you have early adopters, um, early majority, late majority, and I think we're still in the early adopter phase because there is, um, a little bit of, uh, um,
[3:24] Speaker 2: Technical difficulty. They're, they're, they're, they can be somewhat bulky. I, I, I consider myself an early adopter for the most part, and I've used um
[3:34] Speaker 2: Uh, you know, most major systems at some point in my career. Um, but to make the transition to the mainstream market to really get over that hurdle, hurdle, you have to have increased clinical value. You need to make it, uh, improve the ease of use of, of the device, have favorable economics, so the cost needs to come down, and it's got to be faster, safer, and easier to use. That's the bottom line.
[3:57] Speaker 2: Uh, these are the, uh, current systems on the, on the market. They're, um, somewhat bulky. They kind of rely on the same, uh, Northern Digital type camera. And then this is just a smaller, more compact form factor. I think I have a video coming up of me using one of the, um, Other devices. Uh, we have one at our hospital. And, you know, you, you're sitting there. Time stands still. I'm just waiting.
[4:23] Speaker 2: For the robot to get into position. And I'm like, OK, OK, let's go. No, not ready yet. Oh, OK. Still not ready. OK, now I can put in my screw. Now, now I can, you know, now I can start. But it's just, it's just that lag and, and, and, and, and, and that, that system when it came out was one of the more elite systems. And I just think, you know, if you're running a busy Private practice, we, we do about 5 or 6 cases a day, um.
[4:50] Speaker 2: Averaging around 10 cases a week, 10 to 12 cases a week. And uh to keep things moving along, you know, I wanted something a little bit more efficient. So, I started uh doing some homework, looking at different systems. Uh, John Painna out of Buffalo did, um, meticulously records uh um his large experience, probably one of the busiest, um, um, surgeons with a mazer robot and recording times. And he, and he, what he found is that, um,
[5:17] Speaker 2: The accuracy was very, very similar, but the Efficiency and, and timing, having a smaller form factor, having an arm that where the surgeon's more involved, the surgeon's engaged to move the device to the location has made things uh significantly faster. Accuracy is the same, guys, but, um, the Efficiency is better and the cost is about 1/3 of the cost for the Other, Other devices. So, um, there's multiple ways to do image acquisition.
[5:45] Speaker 2: Um, going from getting a, a, a conventional, um, you know, three-dimensional fluoroscopic view with an Oar. You can use Other devices that are in your hospital. Uh, I prefer the 3DC arms that are coming out and then,
[5:59] Speaker 2: This is something that's gonna be, I think, really big is using just the, the standard 2D fluoro system, kind of like how Doctor Albar uses a tracking system. He's just using 2D to place the device and once we get that, once we get that going, I think that's
[6:13] Speaker 2: Um, really gonna make this a more practical thing cause most, most Surgery centers already have this, this Technology in place. So there's not a big, a lot of big capital expenditures. Uh, again, this is the, the form factor. It's just smaller. You move it yourself, you're not waiting for the robot to get into position.
[6:32] Speaker 2: And you, you can, um, you can just, uh, accurately place, place your screws in a more consistent, measured, uh, fashion. And that's, that's how a lot, a lot of our games are done. They're incremental improvements that you aggregate, and that's how you get more and more efficient. When I first talked to Doctor Sharon, I was like, how are you doing TLs in an hour? It takes me two. And it's just, this is like getting a good team together, that, that's where you.
[6:57] Speaker 2: Start and then incremental benefits. You don't just try to start and make your tee lift under an hour. You say, OK, well, how can, how much time does it take me to put in each screw? 4 minutes a screw. OK, so we're putting in 4 screws. How, how, how do we make that a little bit more efficient, uh, you know, um.
[7:14] Speaker 2: We have moved to doing our blocks in the prep and hold area for Efficiency. What we wanna, uh, when I wanna come in, we wanna get started. We don't wanna make that, um, uh, uh, a loss of our, of our OR time. We're always running two rooms, and I wanna kinda come in and just get going.
[7:33] Speaker 2: So less but better. Um, Peter Ramsey, he's a designer and a minimally invasive Surgery, in my opinion, whether it's transcambin, whether it's, uh, tubular, whether it's endoscopic, it's not a procedure. It's a philosophy. It's a philosophy. So, who, what, what, who are involved? Who are your stakeholders looking at? Um, so you have surgeons, the staff, the facility, you know, what are, what are, what are their roles? Well, pairers like
[8:00] Speaker 2: Um, the Surgery center because it's less costly to them, and there's more standardization of the cost, there's better Patient Selection, um, so patients.
[8:09] Speaker 2: Um, are, are more appropriate for, for the, for the operation. And there, there's fewer upcharges for downstream consultants. When I was in, uh, training, we had an expression, when the ship's going down, you gotta load the boat, consult everybody. We'll consult hematology, we'll consult, um, infectious disease, we'll, we'll get an Ultrasound on everybody before we put on the squeezers. We'll get all, we'll get post-op.
[8:31] Speaker 2: CT scans on everybody. These are all downstream of charges that are borne by your payers, so they don't like that. Um, why do surgeons like the AAC? Well, there's more empowerment. Um, I'm proud to say in RAC it's still paper charts. It's very simple. It's, uh, it's, it's a more a team Approach, more consistent workflow, and being an owner in the, uh, AAC gives you a pride of ownership. I like to say.
[8:53] Speaker 2: When I'm the last one leaving the Surgery center or something, I, I flip off the lights like a dad, you know, I just, I, you just, you, you really feel like this is something that you're a part of and um you wanna continue, continue to grow it and um make it a great place to for your patients.
[9:10] Speaker 2: Patients get aligned with a physician who's really truly interested in minimizing collateral damage and reducing their Pain. So now Pain control is a big priority that I can't say that was the case, um, uh, in the past. Well, you're in Pain, OK, well, here's your PCA we'll park you on the floor, we'll try to get you moving. Uh, we don't use PCAs. We don't use them.
[9:32] Speaker 2: Um, a lot of talk about regional anesthesia. This is, uh, and you can see the cover article, uh, for, from Journal Neurosurgery with, with Doctor, uh, Abode's article on here where he, he went into great detail, so I'm just gonna go a lot, uh, a lot quicker over it, but
[9:49] Speaker 2: Your candidates for um Awake spine surgery and Outpatient Surgery really should be uh relatively healthy, limited previous Spine Surgery, and in good mental and physical health. They need to know prior to Surgery what to expect. This is not something you spring on them that morning. They, they learn about it in the office, what kind of expectations to have. We, we do prehab with Physical therapy prior to Surgery, so they know how they're gonna get around, how they're gonna move, uh, after Surgery. Um.
[10:18] Speaker 2: It does require gentle handling of tissues, um, and knowledge, uh, of regional anesthesia and a, um, and a, a team Approach and, um, humanism, you know, humanism, respect for the patient. They're gonna be awake. You need to have some empathy about what they're going through. Um.
[10:38] Speaker 2: Uh, this is, uh, Doctor Mummanti, and, uh, you know, kind of doing Awake Surgery out in California, seeing, seeing it's cutting recovery in half, and we're seeing that all across the country. Um, Doctor Albar mentioned the decreasing in narcotics. Patients.
[10:54] Speaker 2: Like are, are, are, are pivoting towards Awake Surgery because they get better faster. And um just to lay, uh I think we've talked about this before. This is, you know, in some cases, there can be really uh scandalous charges for uh intraoperative neurological monitoring. I, I use a trigger EMG uh for pedicle screws for microdisc uh lamin uh laminectomies. We don't, we don't monitor.
[11:17] Speaker 2: Um, you can avoid the risk of general anesthesia altogether. General anesthesia is very, very safe. It's super safe, but there are risks. Um, diastolic hypotension during induction. I've been told that, um, going induction puts a lot of stress on your heart. It's like an elephant sitting on your chest. Um, I've heard Mike Wang say that hypoxia at high altitude. Um,
[11:38] Speaker 2: Uh, post-operative nausea and vomiting, that's, that's gonna be a reason why your patient is not gonna mobilize and go home. Um, and then, um, it, it makes the operating room a more patient-centered and respectful environment. Uh, we know there's some bad actors out there during the COVOID uh surgeon thought he could go to traffic court during Surgery. That just doesn't happen when the patient's awake. We're, we're focused on that patient, not the, not the next patient, and not what we're doing in the weekend. We keep a more respectful, um, environment in our operating room.
[12:08] Speaker 2: Um, I'm gonna touch on, I think it's been mentioned before, um, post-operative cognitive dysfunction, thought to be, uh, more common in elderly folks. I think you can see it at extremes of, of ages. I think it's related to birth suppression that you can get with a general anesthetic. There is a, um, anesthesiologist follows something called MAc, minim, um, minimum alveolar concentration. There's an age-adjusted Mac, um, that needs to be done. If you have a good anesthesiologist, they're gonna adjust the Mac for age, but there also probably needs to be done.
[12:37] Speaker 2: And altitude adjusted max. So we're, I was seeing one early in my experience, a lot of confusion, difficulty with the executive function and memory that we, we just kinda said, well, I hope it's gonna get better. But um, by doing, using more regional anesthesia, we're seeing less postoperative cognitive dysfunction. Um.
[12:56] Speaker 2: We are the author of this paper, uh, here, but decreased fatigue, improved quality of life one month after Surgery. Um, Kingsley went into this, uh, earlier today, so I'm gonna, I'm gonna leave that to him. So, why do I do it? So this is just only a few hours after Surgery. This is a 70-year-old, uh, female. Um, this is 4 hours after Surgery, you know, getting people up, mobilized, and, uh, on their way. But
[13:18] Speaker 2: One of the things that you're gonna see is that we've started using uh ambulatory infusion pumps. And when I first started using them, I had them on a continuous infusion. But then after talking to, seeing Doctor Bullet's talk in San Diego, I was like, maybe we need to do intermittent bolus. So now the pumps are programmed to give an intermittent bolus about the, the amount of pressure you'd get with a um.
[13:41] Speaker 2: With a 10 cc syringe, and we're seeing that we're even using less, um, less ropivacaine doing that and it lasts longer, so it lasts up to 5 days. Um, we, um, presented this in, uh, JNS case studies, and des describing the, uh, technique which, um, I'll invite you guys all to, to check out that article.
[14:00] Speaker 2: All right, so, Pain management, ARS Protocols. I'm gonna say this is how we do it. So we use the ESB catheters. Um, so we're doing a little bit of everything. A spinal anesthetic for T-lifts, ESB catheters, and a T-lip block. So we kind of do every single block that we can because, um, we need to. I'm not, uh, uh, I'm not claiming to be a great surgeon. I think I'm an average surgeon, but I have amazing anesthesiologists and an amazing team Approach, and that's what allows me to do this. The Surgery is similar. Um.
[14:29] Speaker 2: This is how we do it. We do it in prep and hold. We use an Ultrasound. This has been kind of, um, uh, already, uh, discussed earlier today. Um, and then we're seeing, you know, 30%, uh, discharge within 10 hours of Surgery, you know. And this is, uh, all comers. This is not only just Tlis, this is Ali, this is, uh, and laterals as well. We do the same, uh, um, ESB catheter block.
[14:53] Speaker 2: Um, also, a trend, a trend towards earlier discharge. This is our Kael-Myer curve, uh, measuring discharge is the Primary endpoint. And with the awake cases, the discharge tends to be a, a lot sooner. And I think when we, this is about, uh, I think 80 patients, I think when we add in our, our more recent experience over the last 6 months, we're gonna see that gap widen.
[15:12] Speaker 2: Um, uh, I'll talk a little bit about, um,
[15:16] Speaker 2: Uh, inner innerbo choices and why I try to use bidirectional, uh, um, implants in, in the ASC. This is a case that I did a long time ago, I think in 2016. I was really proud of myself for the small incision that I did and, and we were able to get a small cage in, but then, um, then boom, you know, this happens and you're like, oh jeez, did I really get an adequate discci? Why, why did that cage fail? Why did that cage subside into the implate? And it's because it only expanded in one direction.
[15:44] Speaker 2: Uh, I did a lot of point loading on, on a, on the softest part of the bone, and, um, that was a failure. It needed to be revised.
[15:54] Speaker 2: So, like anterior cages and lateral cages, bidirectional cages give you a much larger footprint. Um, I think the largest one now is about 17 millimeters wide. That's a large cage for a TLlift Approach. Revision surgeries are costly, uh, to revise this patient, and they erode the confidence in you. The patients don't look at you the same as you're say, oh sorry, I, we need to go back and revise this to, to get it, um, to get it fixed. So that's why I've, uh, switched to, um, exclusively, um, bi-directional expandable cages.
[16:25] Speaker 2: All right. So, uh, you gotta put your tigers in the cage, OK? And so whether you're doing an a lift, uh, you, you might need, you need to deal with the, uh, the vessels. If you're doing an O-lift, you're gonna deal with the ureter. If you're going, uh, direct lateral.
[16:39] Speaker 2: You're dealing with a plexus. And so when we do a t lift, you gotta deal with the nerve. And so how do we deal with that nerve safely? It's by starting off small.
[16:48] Speaker 2: Minimizing neural retraction and then once you get in to the disc space, then you expand. So it's building a ship in a bottle. I've heard guardianing through a picket fence. You're, you're, you're starting off small and then you're opening up lateral. And then when you do this, you can get a really big cage. This is a flare hawk 11 cage. It opens up to 17 millimeters wide.
[17:07] Speaker 2: You can see um pedicle to pedicle coverage, the medial portion of the pedicle coverage, good height registration. The guy's awake. I don't know if you can notice this, but he's got his phone down here. He's kind of mess, he's like a, you know, I mean, everybody's gotta have their phone. He didn't want to go in the OR with his phone. So, and listening to his own music, and I, and I think that um.
[17:26] Speaker 2: Uh, Doctor Albar mentioned listening to music reduces stress. I really think that listening to music, um, gets you through it, you know, it's kind of like being at the dentist's office.
[17:35] Speaker 2: Um, this is a little bit about the insertion profile. You can see that you're minimizing neural retraction. You start off small, you get into the, uh, the disc space, and then, um, then go ahead and expand. And then we backfilled a lot of the earlier cages with the mechanisms for their expansion that had you a really limited graph window. Well, you, we can get routinely up to 10 cc's of bone graft in by backfilling the cage. There's no need to prepack the cage. You put the, you put the device in and then you backfill it.
[18:05] Speaker 2: OK, let's get back to that case that we had earlier today. So I, I recommended you have an Outpatient awake, uh, TLLft. This is, uh, a pre-op x-ray. This is your post-op film, um, during Surgery. Uh, these are the sagittal spinal pelvic parameters. Uh, you can see that lordosis didn't increase all that much, but we didn't make him kyphotic by doing it, uh, this way. Um.
[18:27] Speaker 2: This is after Surgery. Um, you can see that, uh, he's awake in the operating room of your Spine. This guy, uh, was very generous to let us, um, film his, uh, his, uh, procedure for the Discovery Channel. This is, uh, an excerpt from that. Um, so I'm really excited for him.
[18:46] Speaker 2: Hey, Michael, you did extremely well with the operation. This is just only a few minutes after Surgery. Pain levels about 10 minutes. 0 for the most part, just the pressure of the, you might say hammering. Yeah. You mentioned that you had a fair amount of leg Pain before Surgery. How's that feeling right now? So far, pretty good. I can feel my toes. Good.
[19:08] Speaker 2: We're gonna let you recover. We'll get you up and walking and moving around. I encourage my patients, including Michael, to get up in the ambulance. Early immobilization is key. Early immobilization is key. Like I said, using the infusion pumps for intermittent bonus has been helpful. Um, you can see before Surgery, um, walking with a cane, that, that.
[19:27] Speaker 2: Typical kyphotic posture, you know, and then he's got, uh, a more lodotic posture, loss of cane, less leg Pain. Church has changed dramatically too. I'm able to do more, and this is why we do this kind of stuff. We're trying to get people to get back to life, get them back to their job in a faster, quicker way. I'm really blessed to be able to have.
[19:47] Speaker 2: Probably shouldn't have been moving all those chairs, but.
[19:51] Speaker 2: So, I mean, let's look at, you know, the, um, you know, there, there, in order to successfully adopt Outpatient spine surgery, um, a lot of things need to happen. You get, you need to have, uh, a patient who's willing to undergo it. That needs to be a discussion that happens in the office. Uh, you, I explained the benefits, the risk of general anesthesia, improved professionalism, and ability to monitor your patient in the
[20:13] Speaker 2: Operating room, examine your patient in the operating room, um, faster, uh, faster recover return to recovery. Now, I've never said that, you know, my awake patients are gonna be, uh, have a superior outcome at one year. I'm looking at days to weeks, like when can this person, person get back to work or back to golf, back to hiking. You don't move to Vail if you wanna be a couch potato. You move to Vail cause you wanna be outside. Um.
[20:37] Speaker 2: Decreases, uh, bleeding loss. This is something that we touched on a little bit. Without under positive pressure ventilation under general anesthesia, when you tear an epidural vein, it bleeds a lot more. Uh, they have relative hypotension and without that positive pressure ventilation, the epidural veins are smaller, so you don't have as much engorgement. So it's easier, uh, it's, it's easier to, uh, coagulate and divide your epidural veins, and, um, there's, as a result, there's less blood loss.
[21:02] Speaker 2: Improved, uh, Reimbursement and with, uh, the models that we run in our RAAC even though it's less costly to insurers. Still, there's, uh, um, a, a really nice, um, uh, we're, we're able to share in some of those savings that were, that are done in RSAC. I use enabling Technology, um, uh, um.
[21:21] Speaker 2: The, uh, ambulatory infusion pumps, dual expanding cages, or bi-directional expanding cages, and, uh, we're adding now Robotics to it and an improved, uh, surgeon experience. Um, I've been teaching this to Other surgeons, um, who come out to visit. This is, uh, uh, Mick, Doctor, uh, Perez Cre out in Michigan. He came out for a visit and I showed him the catheters and how we're doing things. And, you know, um,
[21:45] Speaker 2: Just after that, he's been able to, to move his uh T lifts. He did his first Outpatient T-lift after coming to our course. Patient left two hours after um
[21:55] Speaker 2: Two hours after Surgery. Um, so, in summary, uh, a lot of the things that you've heard today, but Outpatient Surgery empowers surgeons, and I think we'll start to replace Inpatient paradigms. Um, this is, this is the competition for the big white big building, you know, with, um, uh, difficult to park, difficult to locate, and, and, and, and a less personal experience.
[22:19] Speaker 2: OK. Um, I get a lot of, um, consults from, from folks in, uh, Texas, Atlanta. My doc back home thinks I need a T lift. Can I do it here and convalesce here? It's like a, yes, it's a, it's a more personal experience. We avoid the risk of general anesthesia altogether. General anesthesia is safe, but it does have risks. We encourage, uh, you know, um, more gentle handling of soft tissues, making you a more gentle, more humanistic surgeon. I think it's, this has made me a better surgeon. You have to be.
[22:48] Speaker 2: And then greater Efficiency in the operating room. Um, we're, we're not waiting for induction, um, or emergence. We had a patient with acetylcholine esterase sufficiency. Um, it was like 2 hours to get him out of the room, and that, that's, that's time that you're not able to operate, you know, what are you gonna do? I, I, I didn't know that prior to Surgery. I, I figured it out afterwards when they, when you wouldn't wake up after having a paralytic, uh, multidirectional expendable cage.
[23:13] Speaker 2: Gives you a more stable foot but, more immediate stability, and you're not, you're not, um, you're not going by when you're making that pass by that's reversing, um, the exiting nerve root, you're less likely to put, uh, any tension on it. So, ACs are a great place to work. This is a picture of our AC in Vail, Colorado. We just kind of redid all the rooms. We have 4 campuses. This is, um,
[23:34] Speaker 2: Uh, a stock photo of where I live out in Vail, Colorado. Uh, I looked for my hospital there. There's the hospital right there. You can see the helicopter tower, and then there's the ski mountain there. So, uh, patients want to go from there to there. That's, that's the whole point. So I appreciate your attention today. Um, I think, hopefully there's some time for some questions. Uh, I might have gone over my time, but I tried to go quickly.
[23:58] Speaker 2: Thanks, guys.

## In this course

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- [All lessons: Awake Spine Hybrid Course](https://doc.social/llms/courses/awake-spine-hybrid-course.md)