Awake TLIF

Speaker 1So, I wanted to speak today about Awake spinal fusion and, and sort of go through some of our data, but really sort of walk you through the journey that got us to the point that we did.

Speaker 1What I really like to hear is, um, when I hear, when I speak to Ernest, when I speak to Kingsley, when I speak to others, it's, it's sort of the same questions that the patients are asking that have been pushing us to this evolution. So it's nice to see that independently, we're seeing the same kind of demands from the patients that are pushing us in this direction.

Speaker 1As I said to you before, there's a natural evolution which is going on in Surgery overall, but certainly in Spine Surgery, right? And the question is, is that where in the evolution curve do we, are we fitting in and where do you fit in? Um, I think with anything, you'll see there's always this evolution from just traditional open Surgery to minimally invasive. Um, I think endoscopic is still, the jury is still out on the adoption level of it.

Speaker 1But I would argue again that awake is the more natural evolution because this is what the patients are asking for, and that's what's pushing the evolution, what the patients are asking for.

Speaker 1Um, ultimately, as I said before, it's, we've got to be really clear about what the goal is. It's really easy to get caught up in the next, uh, Marketing movement, um, or the next fad. But I think if you're really clear about what the goal is, and if, if your goals line up, then it makes sense to do Awake spine surgery. The way I see it is there's about 3 goals that essentially patients are looking for when they're coming to you for Surgery. One is that they want a safe option.

Speaker 1I think that all of us would agree that many patients are scared to undergo Spine Surgery because of the safety aspects of it.

Speaker 1And by reducing the um surgical footprint, we can help, we could help with some of the safety aspect of it.

Speaker 1Nowadays, I think patients are really just attuned to the fact that they want to get better faster. So they want to undergo Surgery, but they wanna go skiing the next day.

Speaker 1Or they want to undergo Surgery and they want to go back to work within a week, right? Um, well, we're not quite there yet, but there's no question that patients want a safe procedure that will help them recover better and faster. And ultimately, as I said before, that's gonna occur by us reducing the surgical footprint, helping our patients achieve peak performance, and ultimately doing this while we're able to improve their experience.

Speaker 1Now, in a nutshell, this is what our protocol is for performing an Awake spinal fusion.

Speaker 1Our protocol starts with the day that someone decides to have Surgery. Um, I have an amazing, uh, medical assistant who understands Awake spine surgery, and she starts with the education aspect of it. We've learned something subtle is that if you start off the discussion by saying that you're gonna be awake with Surgery, you're gonna get a lot of fear and pullback, pushback. But if you use the words twilight anesthesia,

Speaker 1You're more likely to get acceptance. So oftentimes for elderly people, I say, have you ever undergone a colonoscopy? Well, you had twilight before, right? That's all it is. We use the word awake. We use the word awake because it sounds better than twilight. But if you just start off with something simple as how you deliver your message using the word twilight instead of awake, you're more likely to get adoption.

Speaker 1Then, of course, as Kingsley has mentioned, you have to have your own risk assessment. Um, we're pretty advanced in terms of who we do Awake Surgery on. So I have criteria on who we'll do it on. But when I first started, I can assure you that we're only doing awake anesthesia on patients who are 35 years old and completely healthy. So you've got to figure out what your risk profile is, what your team's risk profile profile is.

Speaker 1And then ultimately, the crux of the awake protocol is the combination of spinal anesthesia and we use the TLlip block, and then we perform a minimally invasive procedure. Now, many people ask me, can you do this during an open Surgery as well? And the answer is yes. What I should say is not that you have to do a minimally invasive fusion, but you should be able to do a

Speaker 1Predictable Surgery, meaning that if you know that your surgical time is 1 hour and a half, it should be close to 1.5. If that's open or a minimally invasive, it really doesn't make a difference. But the reality is that whatever procedure you use it on, it should be predictable. And that's the hardest part. So if you have a predictable team and predictable, let's say, OR time, then you could do Awake spine surgery. And ultimately, if you could, if you can do all this, you can get that safer, better, faster Spine Surgery.

Speaker 1At this point now, we've performed 150 awake spinal fusions. At this point now, our average length of stay is 0.7 days. The only reason why it's not consistently always down is because of social reasons. It's usually not because of medical reasons that patients stay overnight, but in the fact that they live by themselves.

Speaker 1They're 75 years old and they're elderly. So the only reason why we're keeping patients overnight now are really because of social reasons. Um, Insurances are actually moving along too, and we're seeing that more and more insurances approving Outpatient spinal fusion, so that hasn't been a problem. Medicare hasn't been a problem either.

Speaker 1Um, when a patient comes to me for a single-level lumbar effusion, there's a 50% chance that they can go home the same day. At this point now, that's our, um, goal. Our goal is not to get to 100%. I want to be clear about that. Our goal is not to get to 100% Outpatient discharge, but our goal is to be able to correctly identify who can be done as an Outpatient so that from a site of service issue, we could do them in an ambulatory Surgery center.

Speaker 1That's a cost issue. So our goal is not to get to 100%, but predictably be able to say, you're going to be good for an Outpatient infusion. We're going to be doing you at ASC.

Speaker 1And at this point now, um, based off of our, um, exam of the databases, 70 70% of our patients are off of narcotics. The reason why I know that it is twofold. One is because we have access to the narcotic database in both New Jersey and New York. And two, I should just give them enough pills to last them for a week.

Speaker 1So it's actually very rare that someone will ask me for a refill for their narcotic prescription, and we could probably push that down. I think the date is actually closer to 3 to 5 days that patients are on narcotics now. So this is where we're at now. But this has been an evolution for us. This is not something that happened overnight for us. Cause our story, our story started similar to what Kingsley was describing, which is this uh 62-year-old female who had come to me um for spinal fusion. She knew that she needed spinal fusion Surgery.

Speaker 1Prior to this, we were doing our laminectomies um under the awake protocol. And we found such profound differences between awake versus general. We said, OK, interesting. This is great. We had been toying around with the idea of trying to do our fusions under spinal, but this patient had come to me because she was a widow.

Speaker 1Uh, her daughter lived 2 hours away.

Speaker 1And she previously had Shoulder Surgery.

Speaker 1And she knew about some of the cognitive issues related to anesthesia. And she, and when I talked to her about our awake protocol, she enthusiastically signed up for us to do our first Awake spinal fusion. And we did, and it was really uneventful. And what that did was it gave us confidence as a team that we can do this.

Speaker 1And as we did this, of course, there's a little bit of a Learning curve, we got better, um.

Speaker 1Let me see, can you play the video?

Speaker 1This is a Thomas.

Speaker 1Let's see if I'm not sure if we can it'll play the video, with you, Justin, can you play the video from there?

Speaker 1So unfortunately, you can't hear the narration, but um I have to, I have to say this but uh

Speaker 1Um, like, 2. That's OK, no problem. I have to start off by saying that Tomas is an Irishman from a town called Yonkers. Yeah. And I'm not sure if you ever met people from Yonkers, but those guys are tough. And he's Irish, so he's even tougher. So to be fair, this could be some selection bias. Yeah, exactly. But this is Tomas, and in the video, you hear him say that he's walking about an hour or two after Surgery.

Speaker 1And so when we started doing this, we realized that we could do it and we could get them moving. At the end of, at the end of the day, it was a confidence issue. And what worked for me was that I had an amazing team of nurses and anesthesiologists who supported all this. Such that when we started doing this, people, people started asking, why are we not doing it more often?

Speaker 1And so as we did that, we gain more confidence, realizing that we could get them mobilized and get them moving. But, uh, and we went back and critically looked at our data and we found that there's about a 50% drop off in their Pain when we use just spinal anesthesia mixed with fentanyl. And we found that their length of stay started going down. Now, our goal wasn't to get to an Outpatient Surgery, but we started realizing that patients were asking, why am I staying in the hospital, which is actually blew me away.

Speaker 1And so we said, hmm, we don't know actually, cause that's just the way we always did things. But when we started pushing it, we realized that perhaps they could go home sooner. But it really wasn't until this paper came out as Dr. Bullock had mentioned in 2015. Dr. Hand had published the results of the tele block, which essentially is blocking the dorsal rami nerve as it comes out and it innervates the multifit and lumbarrus. And it's been shown pretty clearly that those are the muscles that give you Pain post-op.

Speaker 1And using Ultrasound, it's a pretty elegant, I believe, Approach to doing this. What was interesting was this in his original study, what he did was take volunteers, probably medical students, I assume.

Speaker 1And he would perform the tela block and at different time points measure the anesthesia, where they were feeling numb. And you can see in red how dense of a block they were.

Speaker 1And so when we did this, we said, huh, that's interesting. Why can't we integrate that into our protocol? And we started using Xpril at that time. I'm going to show you our protocol in a second, but I just want you to understand that at this point now, what we do is spinal anesthesia with the tele block.

Speaker 1And the way we do it stepwise is this. In the preoperative holding area, we start to run IV fluids. Because you give spinal anesthesia, you typically, they become hypotensive. So we typically give about 500 ccs of IV fluids. Before we bring them to the operating room or when we bring them to the operating room, we give them Versed. And so they have no recollection at that point.

Speaker 1We've used isobaric spinal anesthesia, and to be honest with you, I'm not smart enough to understand the differences, but Doctor Bullock can tell you more. But isobaric versus um hyper. But we found that with isobaric spinal anesthesia in a very predictable manner, we can basically put the anesthesia on and put the anesthesia off and get them immobilized after an hour or two.

Speaker 1That was a big change for us. The patient positions themselves prone. And what's been nice about that is that the patients can position themselves in a manner or position that makes them comfortable. I think what's so interesting about Surgery in general is that oftentimes we do things that we think the patients would like. But when you start listening to the patient, you realize that actually putting their hands out like this is not comfortable. In fact, elderly females who have Shoulder problems actually like to cross their hands.

Speaker 1So it's not uncommon that patients would actually sleep as if they sleep on their belly, put their hands like this, or sometimes we put their patient, our patients with their face pointed down, but actually some people actually like to be on a pillow, their face with their face out. So it's interesting because it's a different way of thinking because you're sort of listening to the patients. And that feedback has been really incredible because when they wake up, they're comfortable.

Speaker 1They don't have that Shoulder Pain that we typically see. Their neck Pain, they don't have all that. So it's lending to the Patient experience, which I think is so critical. It's not something that we think about a lot during Surgery, and then we do the Tlip block.

Speaker 1So for the Tlip block, there's two parts to the Tlip block. There's a deep Injection.

Speaker 1And there's a superficial Injection.

Speaker 1Um, just to get you oriented, the spinous process is right midline. And then this is one of the few patients we had where their anatomy is beautiful. So, of course, I took an Ultrasound picture of this. And you can see the needle on the right-hand side. Can you play the video, Justin?

Speaker 1So you're seeing now the needle, and it's going to the interfascial plane between the multi fittest and the lumbars. Um, what's interesting is that depending on their patient's anatomy, sometimes you feel a pop when you get to that plane. So as you're putting the needle in, you're going through muscle, you're going through muscle, and then all of a sudden you feel a pop.

Speaker 1And as you get in, you can see the Medicine. And if you look at the lumbarrus on the right-hand side, you'll see that as you put the Medicine in, the muscle moves back. And so you know you're, you're in the right plane because you're not in the muscle because the muscle itself is moving back.

Speaker 1So, we, this is our concoction that we use over here. It's a mix of um Experil and bupivacaine. Uh, it's a total of 20 of 20 cc's 15 deep, and I'm gonna show you 5 cc's superficial. But what we found is that when we started looking into the TA block, there's been some Research done about uh what nerves are affected and how do you get that dense anesthesia.

Speaker 1But there was a paper that we saw, or I'm not even sure if we may have just done like a study of our own anatomy, but we found that um if you do a superficial Injection,

Speaker 1That actually gets the cutaneous nerves as well. So the deep block gets the dorsal rami, it gets the multi fittest in the lumbarri. But if you really want to get a nice block, if you do this superficial Injection, the, I'll play the video in a second, you actually get um anesthesia of the skin itself too, which lends itself to better Pain control. So, this is 5 cc's. Can you play the video, please?

Speaker 1So the same orientation, and you can see the needle coming in on the top right.

Speaker 1So what you see is the needle coming through. You can see the um the, the traccolumbar fascia. Now, we're still trying to figure this out if we should stay above the fascia or below the fascia. But when we go above the fascia, you can see how the Medicine spreads and it bathes the cutaneous nerves. So when we went back and looked at some of the anatomy drawings, we found that the, the, the, the cutaneous nerves come out from the superficial aspect of that fascia and go up to the skin.

Speaker 1And so if you bathe that area, essentially, you're getting that part of it. And by doing that, they feel even less Pain actually too. So there's two portions that we do for the tel block, and I think it's valid for the ESP block as well, that you do the superficial as well as the ESPP block of not really. OK. So you can explain that more. But this, but by doing, by doing this, we found that we've been able to get a dense amount of anesthesia. And then, of course, we do a mini invasive fusion.

Speaker 1When we started doing this, when we started using um uh Excel in particular, we found a dramatic drop-off in terms of Pain. I mean, at this point now, the, there was about a 65% reduction in their maximum Pain scores. That was the big hurdle. That was the big breakthrough for us.

Speaker 1And, and we found that once we did that, honestly, we report opioid usage, but the reality is that I don't even think they need opioids, but the nurses are so used to giving them opioids. I'm not sure if that's been your experience that they just give it to them. And when you ask them afterwards, they say, why did you give the narcotics? Cause, cause we always give narcotics after spinal fusions. And so, that's to, to change that behavior is a little bit too much for me right now, but the reality is they don't actually need much in terms of Pain Medicine. But what was so interesting was this, that when we started adding the TLlip block,

Speaker 1What happened was it helped us get over a major hurdle, which is to make this an Outpatient spine surgery.

Speaker 1And the way I learned this actually was so interesting cause I had a lady in her 60s who um around 6 or 7 o'clock at night had asked to be signed out AMA that night. I said, what the hell happened there? Like, why are you signing out AMA after a spinal fusion? Long story short, she did. And when she came back to the office, I said, why? She goes, doc, I was in no Pain. I was walking around. I asked for some Pain, I asked for some meds, my home meds. Use the call bell. The nurses were busy running a code, I think it was at the time.

Speaker 1So they didn't get back to me for another hour. She goes, look, think about this. If I was at home, and I wanted to get up and use, get my own Medicine, I wouldn't have to ask anybody for it. I could be independent.

Speaker 1And then she's, and honestly, I gave her my cell phone number that night and said, if anything happens, just call me, you know, no readmission. And it helped me realize how much we hold our patients back sometimes.

Speaker 1And that was the big hurdle that we had to overcome. So from a medical point of view, we overcame that. But from a psychological point of view, that story helped me overcome that. And ever since that point, it's been no problem for us to send these patients home.

Speaker 1And that's something I want everyone to understand. So, we found in the literature, and this may have been more of a, like a medical economics um study. If you're going to start moving these patients towards an ambulatory Surgery center, there's costs involved in that, of course, and there's a cost and benefit. And we found that when you're starting to do cases in an ambulatory Surgery center, especially spinal fusion, that you want to have the patients discharged after 4 hours.

Speaker 1There's a cost-benefit issue involved in all that. So when we found that study, we started working on basically pushing our protocol now to not only move to Outpatient, but getting them discharged within 4 hours. What that led to was us really trying to understand what kind of problems and pains they're having after Surgery. And in a predictable manner, as your spinal anesthesia is wearing off, in a fairly predictable manner, we've been able to predict that if you give, I'm gonna go through this in a second, Medicine at certain time points, you're gonna preemptively prevent them from having that.

Speaker 1So 1 hour after Surgery, we give them IV Tylenol. That's because a lot of the anesthesia effects are starting to wear off. 2 hours after Surgery, we give them Valium because we found that a lot of these patients just from the nature of Surgery are gonna start to feel spasms. And that if you preemptively give them that Valium, they don't feel the spasms. And then 4 hours after Surgery, you're starting to do X-rays, you're getting ready for them to go home. If you can give them that Medicine at 4 hours, then you're preemptively going to prevent them from having that Pain spike.

Speaker 1But the challenge in all this is that you're dealing with a patient who's having no Pain and you're giving them Medicine, which is a change in behavior for the nurses.

Speaker 1Because for the nurses, they're reacting often, right? Predictably, I understand they're busy. But what we found that is if you understand at these specific time points, what's going to happen, and you're preemptive give it, they have no Pain. This is what it looks like.

Speaker 1Uh, this is Greg who, um, he had a re-herniation, so we did an L5-S1, uh, fusion. Can you play the video?

Speaker 1So we had talked about uh um

Speaker 1Uh

Speaker 1Microdiscectomy, revision microdiscectomy versus effusion. But again, I'm sorry, in the, in the video, it's narrated, but this is him walking and changed about 4 hours after Surgery. And during the video, we discussed that basically his Surgery was about 4 hours away.

Speaker 1So, um, we don't do this all the time. I don't always do these cases as an Outpatient, but when we do, we've learned that there are issues about the OR that you have to look at that can affect your overall discharge, and there are issues on the floor as well. And but by doing that in a fairly predictable manner, you can get the Outpatient discharge within 4 hours.

Speaker 1Um, when they go home, um, this has been a sort of an interesting challenge because, um, there's a Learning curve associated with dealing with the patients when you go home too. The worst thing would be is if you did an Outpatient Surgery and they went, they got readmitted. Shame on you, right? I mean that really doesn't help anybody. And so, um, we're still toying with this protocol a little bit. I'll, I'll, I'll admit, I actually asked the patients to take Percocet every 4 hours, every 6 hours, even if they have no Pain.

Speaker 1And as a result of that, they get constipated. And so we start them on Colace 3 days prior to Surgery and have them continue.

Speaker 1We haven't, I'll, I'll admit to you that I haven't quite got, been able to overcome that hurdle yet cause patients do still get constipated, but we're trying. And then um they have muscle spasms typically for 48 hours. And so we give them the Flexeril as well. So far, this has worked. This has led to about a 3% readmission rate. So we, we're not perfect yet, but not many patients are coming back to the hospital because of Pain. And then the Other thing I've learned, again, this goes back to the whole Patient experience issue is that I learned this from my colleagues who do Outpatient Hip and Knee replacements.

Speaker 1That when the patient goes home, you have to have a lot more touch points with them.

Speaker 1Where when they're in the hospital, it's easy cause they can just call the nurses, but you have to call them post-op day 1 or post-op day 2 or have your assistant call them post-op day 1 number 2. Cause there's a natural, there's a lot of natural anxiety. And if you don't do that, you're not gonna be able to get a good predictable outcome.

Speaker 1And that's been a hard lesson for some of my colleagues to get. But it really doesn't, I mean, on your way to work, on my way to work, I'll often call them 5 minutes. It's great. Answer the questions, they're good to go.

Speaker 1So, but if you do that, you can get these kind of results. Let's play the video on the left-hand side. This is Jordan. He had an isthmic spondylosthesis. He was in his late 40s. I'm sorry, again, in the video, he narrates all this, but he's talking about how he was about an hour or two after Surgery now. Now, he was very active to begin with, obviously in good shape. This is what he looks like. And can you play the video on the right-hand side?

Speaker 2tiny incision.

Speaker 2OK, let's see you walk.

Speaker 100,

Speaker 2I didn't notice you there. I was just reading about my heroics in yesterday's 5K run.

Speaker 2Uh jordan Simon, three days post-op, had my Surgery Wednesday, August 19th. Today's Saturday. What's today's the 20th.

Speaker 220 seconds, uh, feeling good. Back hurts a little bit, uh, tighten the hamstrings, but pretty ambulatory. Feeling OK. Can't complain too much. Doctor Sharon, you're my hero. Bill, everybody at uh at New Jersey Spinal Wellness, thank you very much. I appreciate

Speaker 2it.

Speaker 1So, uh, I play this video for a couple of reasons. Um, as you're thinking about developing your own awake Spine program, there are different segments to the Learning curve. There's a segment involved in the operating room. There's a segment involved in the hospital, or ASC, and there's a segment involved about when they go home.

Speaker 1At this point now, this is the kind of results that we're getting at, let's say post-op day 3, post-op day 4. But as you're looking at this, you have to look at it holistically across the whole episode. But if you do, in my mind, doing a laminectomy and a spinal fusion, same Surgery.

Speaker 1The results are predictable.