Awake TransKambin Approach

Speaker 1I think what we're gonna do is move on to the uh the next talk. Our next talk is gonna be from Doctor Abdul Barar. He's uh in uh Duke.

Speaker 1He actually, he does a lot of his surgical approaches using the transcameron Approach and uh they've been using um MRI uh to sort of navigate through to this Approach and so essentially, they're doing almost no bony resection at all and able to do both the decompression as well as the uh fusion. So,

Speaker 1Are you there, Mohammed?

Speaker 2Yes, can you hear me?

Speaker 1Yes, we can just raise the volume just a little bit for us. But yes, go ahead and do it. Thank you very much for joining us. Um, sorry, you couldn't join us in person, but next time, I'm really excited to hear about your talk about the Awake TransCanian Approach.

Speaker 2Absolutely. Well, this has been a great morning and uh I'm, I'm really sorry that I wasn't able to join you in person. Uh, I'm actually on call. Um, so today, we're gonna be talking about uh awake transcam infusions and some of the evolution of our techniques. Uh, these are my disclosures. Uh, I do wanna make some disclaimers that I will be discussing some, uh, off-label use of Medical devices.

Speaker 2Um, so just as an objective, you know, I want to review the anatomy of Camden's triangle and then talk about adjuncts that we're using for a safe and efficient entrance into Camden's triangle, uh, radiation reduction Technology, Robotics, and, uh, some of the nerve, new, uh, nerve segmentation.

Speaker 2Um, I think, you know, something that has, uh, come out loud and clear from this morning's talks is that, you know, Surgery, um, is a traumatic event. It's traumatic for the patient. It's traumatic for their loved ones. And we really owe it to them to minimize our surgical footprint. Um, and I think Awake Surgery is a very natural way to do that.

Speaker 2As well as these newer, uh, ultra mini, minimally invasive techniques. Um, so I'll discuss the first case here. We'll start off with a case of a 76 year old lady, uh, with a, you know, uh, pretty average medical history that we all have, uh, who's got pretty debilitating back Pain, uh, as well as some, uh, leg Pain. You can see here, she's got

Speaker 2Um, a two-level spondylosthesis at L4-5 and L5-S1. She really tried, uh, a lot of different, uh, conservative management, including injections and Physical therapy. Um, you can see, uh, on her dynamic films that her 4-5 is actually more like a grade 2. and she was really at the, um, uh, end of her line.

Speaker 2Um, and so, and these are her, uh, parameters here. So, you know, I think it's, you can do the Surgery in many, many different ways. But I think doing a, uh, L4 to S1 T lift would be some way that, you know, a lot of people would agree upon. Um, and so for me, when I look at the Surgery, um, I can kind of, uh, split it up into, uh, different parts, uh, placing the pedicle screws, the intrabody fusion, and plus or minus, uh, decompression.

Speaker 2Uh, and so what we're really gonna focus on is the interbody fusion part. Um, and as we all know, there's been an evolution of techniques for that. So, uh, not a lot of people now docLIPs, uh, because, you know, doing a, uh, bilateral laminectomy and, uh, moving the theca is, um, uh, morbid for the patients.

Speaker 2Uh, as, uh, Doctor, uh, uh, Abodi showed, uh, doing a TLLft, uh, you know, is a minimally invasive way, uh, and it's a very helpful way. Uh, but you still have to do at least a medial facestatectomy, uh, to do that. Uh, what we've tried to do is try to limit the, uh, uh, facet resection, uh, by, uh, really

Speaker 2Uh, using, uh, Camden's triangle. And so as you guys all know, Camden's triangle is a, a zone, uh, that is, uh, bordered by the exiting nerve root, uh, the traversing nerve root, the caudal pedicle, uh, and also if there is the, the superior articulating facet, uh, at, of the facet at that level.

Speaker 2Um, and so, you know, Mike Wang from, uh, Miami has really shown a good job of, you know, this is a three-dimensional space. So it's more of, you know, what we call a prism, um, and you can do different entries here, uh, depending on what you want to accomplish.

Speaker 2So the way that we've, uh, done this is by making a, uh, stab incision about 6 centimeters off of midline. Um, and the way we target it is we use a triggered EMG. So I know there's been some, uh, discussion about, uh, using, uh,

Speaker 2monitoring. Uh, I do think it, it is important in these cases to do monitoring. And we have some evidence to show that some of the normal parameters that we're using for stimulating screws, even under spinal, uh, still works. Um, and so you really want to avoid the exiting nerve roots, uh, uh, on the, on the lateral. And on the AP you want to be in the mid pedicle point.

Speaker 2Uh, previously, how I've been doing this is by using, uh, two C arms, uh, uh, you know, after the patient is asleep. Um, and that took a long time and made people frustrated and so on. Uh, but now what we're using is, uh, some proprietary, uh, radiation reduction, uh, that's now, uh, available, uh, commercially, uh, where you actually put the fiducials on the CR, um, and then you're able to use, uh, instrument tracking.

Speaker 2Um, and we showed that, uh, for entrance into Camden's Triangle, now we have no set up time, and we're able to get in there, uh, very, very fast. And this was in 2021, and I would say that we probably have that time now. So we're getting into this difficult area in about one or two minutes. Um.

Speaker 2Here's an example. Uh, this is not an edited video. So this is a patient with bone on bone, grade 2 spondi, very difficult case. Um, I put in the screws first because I thought that I might have to distract, but I decided not to distract. And you can see here, uh, using this, uh, instrument tracking, we take one X-ray and the AP to kind of know where our position is. We do another one in the lateral.

Speaker 2Um, and then basically we're able to then, uh, see where we are in both AP and lateral. Uh, and so there's no real setup time. Um, I don't have to get a, a long, you know, um, uh, alarm spin or anything like that. And I'm able to then track into, uh, Camden's triangle, uh, in a very difficult case, uh, you can see here in, in about 30 seconds.

Speaker 2Um, and so, um, I know that, uh, Doctor Braxton is going to be talking about Robotics, uh, you know,

Speaker 2As we started getting more and more comfortable getting into Camden's triangle, we thought that this would be a natural, uh, application of Robotics because as we know, uh, robots are pretty good at placing pedicle screws. And then we're also able to then target Camden's triangle. Uh, we kind of, uh, hijacked, uh, the, uh, planning software to get into Camden's triangle. Uh, and you can see here, we're getting into Camden's triangle, uh, using the robot.

Speaker 2Uh, this was my very first, uh, awake, uh, T lift. Uh, you can see here, there's almost no blood loss. The operative time was 2 hours. Patient went home the next day. That really got me thinking and more and more confident, you know, this first case, the patient demanded no general anesthesia because he had a previous, uh, bad experience with general anesthesia. So I probably was a reluctant, reluctant, uh, uh, participant in this case.

Speaker 2Uh, but actually, I have to credit, uh, Doctor Sharon and Dr. Braxton, who kind of helped me, uh, grow my confidence in this ability. And so I started to offer it to more and more people. And this is our, uh, case series of using the robot, uh, for these transcambian approaches. Uh, you can see here in our 1st 10 patients, uh, 4 of them were done awake. Uh, and you can see that our, uh, length of stay, uh, is pretty, is pretty low. Now, you may

Speaker 2be asking yourself, uh, you know, you've talked a lot about, you know, Camden's Triangle, but you've forgotten about a very important aspect, and that's the exiting nerve root. And that was something that I was, um, really concerned about. Um, and so what we started to do then is actually use a high resolution MRI. Uh, we're now using the Brain lab software that allows us to then, uh, segment out the nerves. So we know exactly where the nerves are.

Speaker 2Uh, and then we can actually preoperatively calculate the area of Camden's triangle, and this was a case where, you know, the patient really didn't have any radicular symptoms. And so going in on either side was kind of a dealer's choice. So we chose to go on the side that had a a larger Camden's triangle.

Speaker 2Uh, so now we're segmenting out the nerves. Uh, we're getting a CT scan after we're putting in our screws. We're merging the CT and the MRI and we're navigating into Camden's triangle. So this is our, back to our case of the 76 year old with a two-level spondi. Um, this is kind of our, um, way we did this. We did a pre-op, uh, ESP block.

Speaker 2Uh, then we did the, uh, spinal anesthesia. Uh, we do find that having them bring their own wireless earphones actually helps, uh, decrease their anxiety, um, uh, during the Surgery. Uh, then we placed the pedicle screws, uh, using that, uh, uh, TrackX Technology that I showed. Then we place a reference array on the PSIS. We merge them the.

Speaker 2CT and MRI and then we're able to then choose an appropriate, uh, entrance into the, uh, uh, uh, interbody. Uh, and then we're, here's a video showing that where we can see here, we're avoiding the nerves, we're avoiding, uh, all the, uh, bony structures. Um, and so we're able to do that, uh, safely, uh, and efficiently.

Speaker 2And you can see here, uh, we're able to reduce her Spondylolisthesis. Uh, we lost, lost less than 50 cc's. Um, and this was during one of the, um, uh, Delta variants of the COVID. And, you know, we really were on, under the bullet to, uh, discharge these patients. Uh, and so I was able to discharge the patient, uh, the same day.

Speaker 2Um, these are her parameters here. Um, and so we've just actually, uh, had our, our, our case series now of this merging of the MRI, uh, accepted into operative neurosurgery. Uh, you can see that 4 of these 55 patients, uh, were done awake. And, you know, one, I think I'd like to draw your attention to is now we're measuring our length of stay in hours, not days. Uh, and I think that really is a, uh, a big boon, uh, for our patients and how they're doing.

Speaker 2Um, you know, one thing that, uh, people may be asking is, you know, if I go in with a, uh,

Speaker 2Either a uh uh pedicle placed retractor or a tube that's 160 millimeters and do a fast facetectomy.

Speaker 2You know, does that really make a difference whether you're going through Camden's Triangle at all? Um, so we actually looked at our data, uh, looking at, uh, the MIS T-lifts versus, uh, what we're calling a percutaneous T-lift. Uh, and we showed that actually the people that are having the percutaneous T-lifts are using about 40% less, uh, opioids. Uh, and so I do think that the more we decrease our surgical footprint on these patients, the better they're going to do.

Speaker 2Um, and then, you know, talking about awake anesthesia, uh, we're doing, uh, the study here where we looked at, and this was kind of mind blowing to me, is that 50% of the patients that are going to a fusion.

Speaker 2are using zero opioids after Surgery. Uh, and that to me really was, uh, kind of, mind-blowing. Um, and if they do use opioids, it's significantly less as well. Uh, as well, there's a decrease in time to ambulation. Uh, and so I think that, you know, as we are improving our surgical techniques, as we're improving our regional anesthesia techniques, as we're improving

Speaker 2Or, uh, awake techniques, I really think that these patients are doing much, much better. So just to conclude, um, I think Camden's Triangle is an important landmark, uh, again, to minimize our surgical footprint. When you put it all together, it really helps, uh, these patients, uh, get back to the lives that they, uh, can enjoy very well. And with that, I can take any questions.

Speaker 1That was great. Thanks, Mohammed. I mean, it's really been nice to see this evolution. So, um, a few questions. Um, now, going from general to awake.

Speaker 1And I know that your numbers are a little bit slow right now. Anecdotally, what are, what are the differences that you're seeing with the patients?

Speaker 2Um, so, you know, the things that are, uh, we're seeing are a couple of things. Number one is when a person's under general anesthesia, uh, there's, uh, just a, basically an on-off switch. So they're asleep and then they wake up, uh, and then they have a lot of Pain. Um, and as, you know, people have said today, you know, the nurses are playing catch up. Uh, with the spinal anesthesia, we're noticing that as the spinal wears off, uh, we can, you know, be more on top of things. So the nurses can be more on top of things.

Speaker 2I'm starting to have some Pain, so they can give him some Tylenol. They can give them, you know, some things to kind of calm them down a little bit. I think that's one, big difference that we're seeing, um, immediately post-op. Uh, I think the problems with, uh, nausea and vomiting are huge. And I think that the, uh, cognitive effects, uh, really are things that are, that, that, uh, we're seeing probably more on a long-term

Speaker 1effect.

Speaker 1The Other question I had was, you know, we're, we're hosting our conference today here in uh Parra, this beautiful facility, and they've done an incredible job of really moving the needle on thinking about non-opioid uh Surgery, right? How are you measuring um the amount of opioids that patients are taking? Cause you seem to have really good data collection. We use a state database in New Jersey, but it sounds like you've been doing a really good job of, um, of really measuring the opioid consumption very well. How are you doing that?

Speaker 2Uh, I would say that you're probably doing a better job than us. Uh, the opioid data that I showed you was just, uh, in-hospital, uh, usage. Uh, but I would agree with you that it's very, very rare that a patient, you know, will ask us for refills, uh, of their opioids. Um, but it is very hard.

Speaker 2Hard to quantitate that. And especially since some of them now are leaving, you know, so quickly after the Surgery. Um, I would agree with you that, you know, it's a, it's, it's, it's a change in your practice. So instead of rounding on your patients the next day, you have to do telephone rounds on the patients the next day, uh, which is a little bit different. Um, you know, I can make a shameless plug. There's now apps that can kinda help with that. Uh, but I would say that, you know, that is another change that we're seeing kind of in our practice.

Speaker 1There's a question from the audience, um, uh, do you, do you still need to do decompressions when you do this Approach?

Speaker 2So, so far, what we've been doing is we've been very selective in our uh Patient Selection. So, uh, those patients that are, uh, candidates for the, uh, percutaneous ones usually do not have a radicular component. It's mostly, uh, back Pain component with the Spondylolisthesis. Uh, but I've now, uh, started to bring in the endoscope for, uh, direct decompressions, uh, if I think that that's needed.

Speaker 1This is neat. This is absolutely amazing. I mean, it's really just incredible to see what's going on here. There's another question, can providers and Surgery centers structure the cost of Experil as it passed through to the insurers? That's a great question.

Speaker 1That's probably a dentist question more than anything else. But right now you're using Xpro as part of your

Speaker 1block?

Speaker 2Yes. So, um, for the, I've actually tried to be, uh, naive of what the anesthesiologists use for their block, um, because I do think that it's important for us to look at that data carefully. Um, so yes, we do use Experro, but we also, uh, sometimes use, uh, Ropi as well. Um, and so we, we're undergoing a study now that we're gonna try to look at, uh, seeing, uh, what the difference is between those two.

Speaker 1And actually, to, to Doctor Ratcliffe's question, can block medications be treated as pastor carva? Actually, the interesting thing that I, I, I'm gonna explore when I go back is this, um.

Speaker 1Apparently, patients can take a prescription for Expel and go to their pharmacy and pick up Expro.

Speaker 1And you can't bring it to the hospital because of regulations, but you can bring that to your ambulatory Surgery center.

Speaker 1Sort of like in the, in, in Orthopedics, we do buy and bill for gel shots for the Knee. So the patients, before they get a gel shot, they buy their um gel shot through the insurance company, pay copay, and then, and you can actually do that through Expo, but I have to explore that a little bit more and see if most insurances do it, which insurances do it, but we'll probably start putting out information about that. If that is the case for an ambulatory Surgery center, that's, that's the way um you can pass the cost through to the insurance company.

Speaker 1Great. That was amazing. Thank you, Doctor. That was really a, a beautiful study. I'm really excited to see where you go with this Technology.

Speaker 2Thank you so much for having

Speaker 2me.

Speaker 1No problem. Thank you.