'Patients will demand it': How awake spine surgery will develop in the next decade

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Neurosurgeon Vijay Yanamadala, MD, made history on Oct. 1 when he became the first surgeon to perform an awake spinal fusion in New England.

The novel approach to surgery avoids using general anesthesia and intubation, instead using a local anesthetic to let surgeons examine a patient's neurologic condition during surgery. But this awake spinal fusion was also the first in the U.S. to use an innovative technique that combines spinal anesthesia and a nerve block, according to Dr. Yanamadala, system medical director of spinal quality and surgical optimization and director of spinal deformity surgery at Hartford (Conn.) Healthcare.

Dr. Yanamadala spoke with Becker's Spine Review about innovations in anesthesia techniques and the benefits of awake spine surgery for patients, providers and the healthcare system.

Question: What patient population do you believe can benefit from awake spine surgery?

VY: I recently operated on an 84-year-old woman with spondylolisthesis, who was completely debilitated. She was walking around for several years, barely able to stand or walk a few feet without stopping. Cognitively, she was very sharp, but this physical disability was really limiting her. She saw several specialists in our area for an awake spine procedure, but they all said they couldn't do it. She had a bad reaction to general anesthesia in the past and felt that she could not tolerate it again. These are the patients who really can benefit from this: patients with risk factors that prevent them from getting general anesthesia and those who are older and have delirium or cognitive problems after general anesthesia.

My most recent awake spine surgery patient was a 25-year-old person who had a large disc herniation. I asked him if he wanted to do it awake, and he said, "Yes. Why would I want to do the surgery with an intubation if I don't need it?"

It's not just the older population who can't tolerate it, but the whole spectrum of patients undergoing spine surgery who are interested in this. We know what's happened in the total joint space, where many surgeries transitioned away from general anesthesia to spinal anesthesia. I think this is going to be a growing trend in spine surgery, too.

Q: What advantages can those anesthesia innovations offer spine surgery patients?

VY: In Connecticut, our anesthesia team is quite forward-thinking: We are combining spinal anesthesia with local nerve blocks. We've performed five of these surgeries, including an awake spinal fusion on Oct. 1. These are the first in the country to be done with a combination of spinal anesthesia and a nerve block. The nerve block basically allows us to create a longer-standing block within the surgical site, which dramatically reduces postoperative opioid usage. For patients who have had spinal anesthesia and  a nerve block, we have used zero postoperative opioids. We all know that surgery sometimes requires a short course of opioids, but where we are with the opioid epidemic now, techniques that allow us to limit or even eliminate opioid usage are very important.

Q: Are there significant cost savings with these techniques?

VY: There's no question that there are cost savings. We recently published a paper on the cost of general anesthesia versus spinal anesthesia for spine surgery. Jean-Valery Coumans, MD, is one of the authors on this, along with myself. We found that operating room costs were 10 percent less for spinal anesthesia compared to general anesthesia, which is a significant factor.

The other factor, particularly important during the COVID-19 pandemic, is that patients don't want to stay in the hospital. With this technique, where patients are awake immediately after surgery, they can go home the same day — even patients who are 84 years old. It's made a big difference for them, being able to avoid the risks of COVID-19. In general, I think people prefer to go home. That's another trend I think is here to stay.

Q: Is awake spine surgery something you see being implemented across outpatient settings?

VY: We are transitioning a lot of our spine care to our ASCs here in Connecticut. We have several surgery centers that are part of Hartford Healthcare, and we see a transition happening to these centers. I think awake techniques have accelerated that process.

Currently, a lot of my spine cases are being done inpatient, but I have a lot of experience in the ASC setting when I worked in New York. Efficiency and the patient experience are better when we do these cases in an ASC. Inpatient settings handle a wide array of cases, from a simple discectomy to complex cardiac surgeries and other procedures. Our processes aren't necessarily tailored to an ambulatory setting and getting patients out quickly, whereas the ASC setting really is tailored toward the patient population we're talking about and optimized to deliver the right care. There's no question ASCs make a difference for this patient population who are undergoing surgery for degenerative spinal conditions.

Q: How do you see awake spine surgery developing in the coming years?

VY: I really think that 10 years from now we're going to see awake spine surgery being done in the majority of cases. Patients will demand it. I think payers will also push in that direction, and we as surgeons will come to see its benefits, too — not only for our patients, but for our processes and ourselves. As it becomes more popular, the processes will be developed, and it will be smoother for broader adoption. 

In September, Dr. Yanamadala also became the second surgeon in the world to perform spine surgery with a newly approved patient-specific implant. Click here for more details. 

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