Awake Spine Surgery

Speaker 1It's also great to be here in um in Seattle. This is actually my uh first time in Seattle. I'm I'm surprised that I haven't been here earlier because like Mike was saying that I'm, I'm, it's really clear here in Seattle that um Innovation is uh is really um in the air over here, right?

Speaker 1I had a chance to walk around yesterday and it's pretty clear just by going to the cafes and restaurants. I'm a big uh coffee roaster and just talking to the coffee uh barista you can hear about how there's such Innovation around here and I think it's not just because of all the different companies that are out here but there's definitely a culture that, you know, um.

Speaker 1Uh, in here in Seattle that there's got to be better ways of doing things now. Innovation is something that I've been really particularly interested in for the past 5 years. There's a lot of science behind Innovation, and Innovation is not just about coming up with a new idea. A lot of Innovation is about execution of the idea, um, and I think that one thing I've learned about Innovation.

Speaker 1Is that you can't really be innovative unless you truly understand the problem that needs to be solved. If you don't know the problem that needs to be solved, I think you start going off in all these different directions, and that's where we get lost. And in Spine Surgery, I would argue that the problem that needs to be solved is on this slide right here.

Speaker 1So we've all seen this graph in some way or the Other, um, the population is getting older, more people are enrolling into Medicare, and there's no question that many of these people are going to need laminectomies and spinal fusions as we get older and as the evidence becomes clearer and clearer.

Speaker 1I'm gonna argue that the amount of Spine Surgery is gonna only increase, right? And that's been really borne out. I mean, on the lefthand side, um, SG2 is one of the major, um, consulting advisory companies, and they've shown that year over year there's gonna be about 18% growth in the number of Spine surgeries across the US, right?

Speaker 1And the problem though is that if we remain on this current course of cost in Spine Surgery, we're gonna be hitting a ceiling and a wall that's unsustainable. So we're on this big drive now for value and the question is how can we sort of decrease the cost while maintaining the quality and in my mind from our perspective as surgeons.

Speaker 1The only effective strategy is going to be if we can start moving a lot of Spine Surgery towards the Outpatient arena, right? Short of trying to deny Surgery like Cigna tried to deny one of my T lifts the Other day, short of trying to deny Surgery, I think that the most effective strategy that we as Spine surgeons can take is to try to figure out how to move more and more of these surgeries to the Outpatient realm.

Speaker 1And we're already seeing that, as you can see on the graph on the right-hand side, and Mike Lee, um, I think he was here a few years ago, but he did this great study where he looked at the trends about Outpatient spine surgery, and you're seeing it already. I mean, laminectomies, ACDFs, I mean, there, there's just a growing, growing trend for more of these surgeries to be done, um, in the Outpatient world. But the one Surgery that we haven't really been able to crack too well in terms of moving towards Outpatient is a lumbar fusion, right?

Speaker 1And that's the big, that's the big ticket item that's the one that gets all the press and uh we're not really seeing too much of the dial being moved with lumbar fusions and from an Innovation perspective from a problem that needs to be solved, I think this gap is where we should start focusing on and that's been the focus of.

Speaker 1Our Awake spinal fusion program. What we've been trying to do over the past couple of years is try to understand how can we move lumbar fusions towards this Outpatient realm in an appropriate and a safe manner. That's been the major driver for what we've been trying to do for awake spinal fusions.

Speaker 1So, but the truth is this, I mean, the solving that kind of problem, of course, is not easy. In fact, actually, um, about 5 years ago I made a decision that to understand Innovation, um, I needed to go get a graduate degree and, um, about 5 years ago I, I got a healthcare MBA up at, uh, Dartmouth, and the degree I got was called a master's in Healthcare Delivery Science. I think Bob Hart, who's here, he actually just finished up the program, and it was a, it was a healthcare MBA.

Speaker 1And it was an amazing, amazing experience for me, and we took courses on um strategy and competition and Innovation and my, my hypothesis at the end is in that Business guys really understand how to innovate because that's what they do, and they know how to innovate at scale, which is what they have to do, and I had to go to grad school to really understand that. I think as, as physicians, I'm not saying that we're not creative individuals, but the notion of innovating and innovating a scale is something that Business guys inherently know how to do really well.

Speaker 1So beyond the courses, I guess, on strategy and competition and Innovation, for me what was really enlightening was some of the people that I got to meet, some of the faculty we had, and people that you know, people like Jim Weinstein and Elliott Fisher. I mean, these guys have been trying to innovate at scale, at system-wide levels for a long time, long time. But the one professor I had a chance to really spend a lot of time with who I really enjoyed is um Elizabeth Tisberg. Do you all know her, Elizabeth?

Speaker 1Elizabeth, as you know, she, uh, she wrote the book with Michael Porter on value in healthcare, right? Um, and I spent a lot of time trying to understand what drove her to write this and this whole value discussion, what, what is it that she's striving for, and her, her personal story is very compelling. If you ever get a chance, you should listen to it.

Speaker 1But what was interesting about um what Porter and Tiesberg, what drove them to actually do the Research behind this was, you know, Michael Porter has shown and many people have shown that in any good capitalistic society in any good industry, competition when done properly drives Innovation, right? I mean, you can't, you can't.

Speaker 1Uh, you can't win if you make the same kind of product. It's when you have proper competition that you innovate, right? And, in any kind of industry here in the US you're seeing greater Productivity when you have that Innovation. So the question is why is competition not work in healthcare? That was the driving force behind what, what started them on this Research and they started looking at um at a value from there subsequently.

Speaker 1But for me, actually, what was interesting was in talking to Elizabeth, she said the question is, of course, Innovation is about trying to understand the problem that needs to be solved, but what you got to figure out is who's the customer.

Speaker 1And fundamentally, I think in healthcare, what we haven't figured out is that the reason why we're having such a hard time with value is that if you really want to create value, you've got to understand who your customer is in our particular situation, the patient. Because in Business school, we learned this, this is Business 101 that the first thing you gotta do is sort of organize production or service delivery around how you create value for those you serve. So you start with that individual and then you start to design your services and products around that individual.

Speaker 1That's how any good Business runs, right? Amazon is a great example of that. In healthcare, I think we've been missing out on that. And in Spine Surgery, I would argue that for the longest time, the way we've looked at the problem is this. As surgeons, you know, we do spinal fusions and we do a good job. We have screws, cages, now we have uh robots and uh navigation. And when we look at the unmet needs, we look at, we look at products like the robots and navigation as the unmet need, right?

Speaker 1But I would argue that as we're transitioning towards this consumer oriented value-based world, you gotta flip this chart around because if you're a patient, right, you're coming in for a solution. You have Pain that goes down your leg that prevents you from playing with your grandkid. You have Pain that's going down your leg that prevents you from going to work, and from the patient's perspective, their slice of the pie looks like this, and their unmet met needs are up here and right now that space.

Speaker 1Is being filled with uh things like spinal cord stimulators and injections and pills, and I would argue that as surgeons what we have to sort of look at that slice of the pipe, how we can make our slice bigger. So what is it that's preventing us from being able to do more Spine Surgery for these individuals? OK, that's the basic fundamental problem I think is that we're not competing to how to deliver value for the proper Spine patient.

Speaker 1And when you can start think, when you start looking at the chart this way, you can see this tremendous, tremendous opportunities out there, a lot of unmet needs, and this is what Porter and Tiesberg were talking about in their book.

Speaker 1And this to me is this what it comes down to is that I think that the reason why patients don't have Spine Surgery are three main factors. One is there's issues of safety, right? There's still the elements of Spine Surgery that are not safe. There's of course cost issues and effectiveness issues, and then ultimately experience issues. I call this the triple aim of Spine Surgery, and I would argue that if we can achieve these triple aims, that you're going to see more and more patients actually.

Speaker 1Um, undergoing Spine Surgery, people don't ask about total knees and total hips. Should we, should I get a total Knee or a total Hip? People just question about when they should get a total Knee and total Hip. And so the question should be at some point, when should I have my Spine Surgery once we can overcome all these issues, OK.

Speaker 1So that's fundamentally what we're trying to drive towards in this OA spinal fusion program. What we're fundamentally trying to do is sort of reimagine what the Spine Surgery experience can be like, so people don't, aren't afraid of Spine Surgery, but asking when should I have Spine Surgery. That to me would be the ultimate goal.

Speaker 1So that's sort of the big picture about what we're trying to do over here. I just want to get, sort of give you a sense about all that. But here's the, the, the micro level of details now of all this. So awake, our Awake spinal fusion program is essentially an Enhanced Recovery protocol. It allows patients to recover faster, mobilize quickly with an overall, with overall less Pain. That's what we're essentially have been trying to do for the past uh couple of years now.

Speaker 1And it's all Awake spinal fusion starts with a minimally invasive fusion, um, like many of you, um, I learned a little bit of MIS during fellowship, but I really adopt a lot of it during practice. Um, there was a little bit of a Learning curve around that, but I saw that as we started doing more and more MIS Surgery on the right-hand side, you can see how patients were leaving the hospital quicker. So I saw definitely the advantage of my own practice of MIS.

Speaker 1And then we started pushing the Technology a little bit. In my previous job, I had a significant portion of my practice devoted towards spinal oncology. And while the cases were great, this is an unblock resection we did of someone with um metastatic disease. While the cases were great, the morbidity is high. And so I had a chance to work with a neurosurgery colleague of mine, um, and him and I used some of Mark Mark Bilski's separation Surgery techniques.

Speaker 1And we sort of adapted some MIS Technology towards this and what we started doing was, um, sort of MIS for the Spine tumor patients. This is a guy who um had a four level ah um minimally invasive fusion and he was walking by the next day.

Speaker 1So we started pushing the Technology and I saw that in, in a population that was so vulnerable that when you do MIS you can really get some dramatic, dramatic improvements over here. So I, I didn't need to be convinced anymore about the value of MIS.

Speaker 1But really my turning point, the light bulb went off my head when I was involved in this study over here. Um, Amanda Tao, who's the first author in this paper, was, uh, doing her MD PhD. I served as one of her mentors. And, um, the last author is Joe Vergesi. He's a neurologist, um, and he had noticed that in when he was being called for consults in the hospital and post-op that many elderly people were coming in with, um, delirium after Surgery.

Speaker 1And during her during her MD PhD, Amanda did some standardized testing and found that no question that elderly patients who undergo general anesthesia have higher rates of delirium when compared to individuals who have spinal anesthesia, and that data has been played out so many times over. The problem is that the complications with it are high. This is a paper that comes from Duke that shows that elderly patients who become delirious have higher rates of readmission.

Speaker 1Right? So as we're pushing these patients out earlier, the reality is that you can be operating on a 75 year old, doing a laminectomy, sending them home, and they're delirious, right? And that's a problem. And so it was with this study that we started converting all of our laminectomies to spinal anesthesia, OK?

Speaker 1And then luckily, um, soon after I, I, uh, luckily I just, I, I changed jobs after that and um I got a chance to work with some really, um, progressive, uh, Private practice anesthesiologists, showed them the data, and said I want to start doing all my laminectomies on the spinal, and it wasn't a hard sell for them. So about 100 cases later, we went back and I had a student of mine look at um our results. And when we do our spinal, besides giving the marking, we also give fentanyl.

Speaker 1And we found that when we did that, these patients are actually having almost no Pain after Surgery. And not only that, but they're using less opioids. So now you have this population of people who are having laminectomies and quite honestly, it's almost like they didn't have Surgery. It's so comfortable. We give them at most Versed or Benadryl and that's it.

Speaker 1So they come in and we always, we see it's like a Chinese massage. They come in, they get the spinal, they position themselves on the, on the table, have the Surgery. By the time we're done, um, the spinal wears off and they're getting ready to get up and walking and moving. We actually just published about our cost effectiveness data and, uh, we showed that there's even a 10% savings, uh, when you do this, and a lot of it is time-based. And if you're in the Business of trying to save money, I mean, it's, it's really hard to save money in a laminectomy because it's not too much waste, but we're able to show that we could even save money that way as well.

Speaker 1So for me I was like, wow, this is, this is amazing. I mean this, this spinal anesthesia and laminectomies, it just, it wasn't something I did in practice. And so then the natural question of course was how can we adopt our spinal anesthesia Protocols towards a lumbar fusion. Mike just stepped out, but you know, it's around this time that I saw this, um, I heard about this guy Mike Wang, and he was doing something called Awakeke fusions, and I was like, oh, that's an interesting concept, brought this back to our team.

Speaker 1And said, can we start thinking about using our spinal anesthesia Protocols for lumbar fusions? Is it, is it possible? And of course lumbar fusion is a little bit more entailed of a Surgery. There's a few more factors involved. It requires talking to the patients properly beforehand, of course some issues around the OR and then some post-op issues as well.

Speaker 1But our team felt, we felt very comfortable. We were doing MIST lifts. We had fairly predictable times. I have a fairly predictable team, so we felt very comfortable being able to adopt our spinal anesthesia Protocols to, um, fusions.

Speaker 1And so we did. This is, uh, this is one of the first cases we did. This is Barbara. Barbara was in her 60s. Um, she had previously had Shoulder Surgery under general anesthesia, so she knew the effects of general anesthesia. She's a widow, lives by herself, was really, really scared about um undergoing general anesthesia, but she needed to have Spine Surgery. She had, you know, um, back and leg Pain, and so I spoke to her about, you know, trying, um, our spinal anesthesia Protocols, and she said enthusiastically, yes.

Speaker 1And she did. And there was just a routine lumbar fusion, MI MIS, and she did great. And in fact, I asked her to go online to write um comments about it and um she said that in less than 2 weeks' time, her Pain was better and somehow or another, she was 2 inches taller, which my graph was not that bad.

Speaker 1But I took it, I'll take it. But she did, and she did wonderful. Um, and then soon after, uh, we started doing it again. This is, uh, Thomas. Thomas is an Irishman, construction worker. Um, he had had a herniated disc and had underwent microdiscectomy. I think about a year or two later, he, uh, re-herniated.

Speaker 1And so because of the way he looks and the work that he did, I felt that he would benefit from a lumbar fusion instead of a revision microdisc. Can you play the video?

Speaker 1In the back.

Speaker 1Can you hear me?

Speaker 1Lee.

Speaker 1Can you play the video, please?

Speaker 1So unfortunately there's no audio, but this is, uh, I have, I often ask the patients just to narrate, but this is him about 1.5, 2 hours after his Surgery.

Speaker 1And to be fair, what, you know, we, we have a fairly predictable team, anesthesiology, um, uh, nurses and whatnot, so we've gotten to the point where we can time our spinal anesthesia so that it wears off by the time that we're done.

Speaker 1So by the time they come back to the PACU, they're ready to wiggle their toes, and about 1.5, 2 hours later they're up and walking because their motor strength is back. So look,

Speaker 2this

Speaker 2patient had a spinal anesthesia plus

Speaker 1the block. Not yet. I'll tell you about the block comes later, got it, but this was just, this is one of our first cases of just spinal anesthesia, and he's Irish, so these guys are tough.

Speaker 1But, but with all due respect, I mean, he just had spinal anesthesia. No, I think maybe Versed or maybe Benadryl, but that's it, and it's really just minimal.

Speaker 2And is the protocol for the spinal any different from any Other spinal that the anesthesiologists give?

Speaker 1Um, everyone has different Protocols for spinal anesthesia. There's two types of spinal anesthesia you can give isobaric versus hyperbaric. Um, hyperbaric, uh, is not as predictable in both onset as well as weaning off. Isobaric is more predictable, um.

Speaker 1Uh, so we use isobaric and then there's the doses will change a little bit based off of which one you use as well. But so we give isobaric anesthesia marking 0.5% and fentanyl. So the reason why we can get them walking so soon is because the, the marking will wear off before the fentanyl will. So there's a window where they're having no Pain, but their motor strength comes back.

Speaker 1And so we, we use that to our advantage. And so what, what I learned is, um, sort of just, you know, keeping track of all this is I have a sense of when the fentanyl is gonna wear off. So before the fentanyl wears off, we'll give them like Percocet or oxycodone so that they'll never fall behind on their Pain meds, and that, that took a little bit of work. But once we started getting that, it was as long as you can preemptively give them the Medicine, they, they don't feel much Pain.

Speaker 2So, so how about the post, postoperative in the PACU though with respect to their motor function?

Speaker 1Well, if we, if we time it well, by the time they come back to the PACU, their, their motor function comes back. What doesn't come back for a little bit while, it took me a little while to figure this out, is that motor wise they, it comes back, but their proprioception doesn't come back as quickly. So it's interesting because they're 5 out of 5 of their strength, but when they try to stand up and walk, they buckle.

Speaker 1Really, that, that was, uh, I had to learn that lesson a little bit. Isn't that dangerous then? Like if you try to get, so that's why, so you don't want them to walk that even it's, so you don't want them to walk that quickly. So even after that motor comes back, you still want to wait half an hour, 1 hour before you get them to walk. They'll come back, but you can get fooled to think that since their motor sh came back, they're ready to walk. So you, you have them sit on the side of the bed, put their foot on the ground. Can you feel, can you feel your foot on the ground? No, OK, fine. You're not ready yet.

Speaker 2So are these patients typically in the PACU longer than a typical general anesthetic for spinal Surgery,

Speaker 1really shorter because the, the, and the nurse, each hospital is probably different, but they have a stage 1, stage 2 Protocols, and so stage 1, so they're, they're already coming in at stage 2, so they could almost go upstairs.

Speaker 1After that, so they're, so part of the savings comes because they're in the PACU for less time.

Speaker 1OK, so that was, that was sort of the beginning of my Learning curve with spinal anesthesia and then so we had our student go back and you can see here, these are just the Pain scores. This is basically the maximum amount of Pain that they, they had in the hospital. So, red is a general anesthesia, blue is a spinal anesthesia. And then we went back and looked at their length of stay, and actually what was interesting was that, I mean, since they were feeling no Pain or minimal Pain, they were able to go home. So our average length of stay went down to 1.1 days when we started using spinal anesthesia.

Speaker 1Now, what was interesting was this, but um a couple of years ago, I was in India teaching a course and um there's a great, great Spine surgeon, Bava Garg, who taught the um the symposium with us and uh he had told me about this, uh, this paper that was published in 2015 describing something called a TLlip block, T L I P, thocallumbar interfascial plane block, and he was gonna start using it.

Speaker 1And, and if you're um an orthopedic surgeon, you know that, you know, a lot of, a lot of the advancement in Hip and Knee replacement came because of all the regional blocks that they um have come up with.

Speaker 1So in Spine Surgery, uh, this group in Canada did something called the tele block, which is blocking the dorsal rami nerve. So the dorsal rami nerve comes out, we know this from out of the facet joint and it innervates the multi fittest in the lumbars.

Speaker 1And if you can use an Ultrasound, you can deliver Medicine in that interval, right? And if you do, diffusely, it will block the multifittoin lumbarrus. So we started using, doing the TLlip block uh using Experil.

Speaker 1And um that was a game changer. Once we started using the TLlip block using Expril, the results were dramatic. So at this point now, our protocol is this, uh, we, we use spinal anesthesia, isobaric.

Speaker 1We use the tulip block. For fusions, we're using Experil, for laminectomies, we use Marcaine because of costs.

Speaker 1And then we do minimally invasive lumbar fusions and then I, I put this in a lower font, but I, I really wanna make sure it's, you have to understand that you have to do proper risk assessment on these patients, proper education. You can't do all this kind of stuff unless you're sort of talking to the patients differently, and I know that it's not the sexy part of things, but that risk assessment, inclusion, exclusion criteria, pre-op education is so critical.

Speaker 1And then post-op, you know, we try to minimize narcotics as well. But it's really the whole package that's been able to get us these kind of results. So at this point now, by doing this protocol, you can see that the maximum Pain scores are down to about 2.1. So basically, in the hospital, how's your Pain, how's your Pain 1 through 10? The most of these people will say is a 2 when they have the spinal plus the teal block.

Speaker 1This is really cool. Um, opioid use is, it's almost, it's almost minimal really at this point now. I mean, I told you, as long as you could be preemptive about it and be balanced, these patients are not taking, uh, opioids, and we've been able to show about a 70% reduction in opioid use in the hospital.

Speaker 1But what's been really, really neat is this. So, um, when we started doing this, patients were asking us, why am I here? Why can't I just go home? And it was sort of fortuitous. There was a couple of uh cases where the patients just wanted to go home and I was like, holy cow, like, you actually want to go home after a lumbar fusion? They said, yeah, there's no reason why for me, I should be here. So at this point now, our average length of stay for a lumbar fusion single level is 0.8 days.

Speaker 1And here's an example. Um, he's, uh, Lee, can you play this? So this is, uh, this is Kevin. Kevin also had, um, a herniated disc. He re-herniated.

Speaker 1And so the question was, he had a DDD at L5-S1 and the pre-herniation.

Speaker 1And so, um, we decided to do a lumbar fusion on him. I felt because of his size that it was probably the best thing to do. At this point now, we do a single level lumbar fusion one.

Speaker 1When, when our game is on, when we're all in sync, we could do a single level lumbar fusion.

Speaker 1Um, about an hour they go to the recovery room and then 4 hours later we get them up walking as you can see over here with Kevin. You can't hear it on the video, but um on the video he's saying that I had Surgery at 8:30 and now it's 2:30, but our protocol now is single level lumbar fusion recovery room.

Speaker 1Um, up walking within 4 hours, antibiotics, X-ray, going home. I'm aiming for 4 hours because as you move these cases towards an ASC, there's a, there's a cost-benefit ratio that happens after 4 hours. You don't want the patients staying in the, ideally in the ASC more than 4 hours, so I'm basically driving my protocol so that within 4 hours I can get these patients getting ready to go.

Speaker 1So now we have, we have our whole pathways and order sets and everything set up so that within 4 hours up walking and ready to go home. I had Kevin changed uh for this video so you can really appreciate how these people are doing over here.

Speaker 1So this is the Awake spinal fusion and as uh as Jeff has said, we just, we did our 100th, um, I think about a week or two ago. We've actually done 102 cases now of uh Awake spinal fusion. Um, it's been a very iterative process and trying to be very methodical and, um, in that what we're doing, Mike had talked about industrial engineering and it

Speaker 1I mean from Business school I learned all about operational Efficiency and so we're, we're, we're religious about operational Efficiency and Business and um improvement like that, but we've done 102 cases. Um, our average lengthSA is 0.8. If I add in the workers' comp populations 0.9, technically, that's, that's a tougher population for me to, to work on. Um, when we first started doing this, about 30% of the patients were going home the same day, and, um, 50% of them are going home now, same day in 2019.

Speaker 1And everyone always asks me what my goal is. Is the goal to get to 100%? That's not my goal. My goal is not to get to 100% Outpatient discharge rate. My goal is to be able to accurately predict who can go home, and for that, that should be 100%. So there's a, there's a, there's a portion, there's, I've learned now that there's definitely a portion of patients who we are overserving when we do lumbar effusions and keep them in the hospital.

Speaker 1So my goal is now to figure out who those patients are so that we can discharge them home the same day, using whatever criteria we, we've sort of been developing. But what's been really neat now is that about 70% of our patients um are off of narcotics within one week. The 30% typically are people who are not narcotic naive. Those, that's a different type of population, and that's something that maybe in the future we'll work on, but generally now we could do a lumbar fusion on a patient.

Speaker 1And pretty comfortably, uh, pretty confidently, I could tell them, tell you that I can get them off narcotics within a week.

Speaker 1So, earlier I talked about Innovation and um how you have to know the problem that needs to be solved, and you have to know who the customer is and what it is that they value.

Speaker 1So for us, the Awake spinal fusion program is our attempt at solving this problem. Um, spinal anesthesia versus general, safer, no question about that. No one's been converted to general anesthesia.

Speaker 1Um, it's cost effective. We showed with the laminectomy data, it's about 10% savings and we're in the process of writing up our paper about the lumbar fusions. Just, just looking at it straight on, we're saving about 10 to 20%, but if I started looking at things like moving these cases over to an ASC, the Cost Savings are tremendous. So it's definitely gonna be cost effective.

Speaker 1And the third one, the 3rd factor which I really didn't touch upon is experience, and I know we don't really talk much about Patient experience in Spine World, but um, as you know from Apple and Amazon, and patient, I mean experience, experience is not satisfaction, right? Experience is what's gonna give you the competitive advantage.

Speaker 1Um, and trying to understand what can make Spine Surgery a better experience is what's gonna make this Surgery better and more people will adopt it. So, um, I'll give you an example. So, but a couple of years ago when we started doing our laminectomies in the spinal, patients said, Can I bring in my headphones and listen to music? I was like, well, that's crazy. I said, sure. And then subsequently, we've offered that to many of our patients, and many of our patients come in now with their podcasts or with their, um, their iPhones and they come and listen to music.

Speaker 1And so we, we asked him, and some patients stay awake and actually just change the music while they're playing, while they're having Surgery. Some people just listen to music and fall asleep. But here's a video from, uh, a colleague of mine. This is my, uh, my partner Bill Jimenez. He's a Primary care doctor. Um, can you play this video? I don't know if you can see it, but he's a little bit of a clown too, but he had a lumbar fusion, and this is him with his big boss, uh, speakers while we're putting screws into his back over here.

Speaker 1So you can imagine, you can it's OK, it's OK. But you can imagine now when a patient's coming in for Spine Surgery, listening to music, how you're basically affecting it from an experience point of view, right? And, and more and more we'll try to drive the experience factor as we get to learn more and more. But to me, this is gonna be the game changer because at some point, people won't even think twice about having Spine Surgery because the experience will be so good.

Speaker 1OK. So thank you for that and thank you, Jeff, for the invitation. If you have a moment, um, you know, this is obviously a fairly novel procedure. Um, we're trying to be diligent about our data and whatnot, but, um, I use our Social Media post, Social Media a lot to, uh, post about different articles about Awake spine surgery and, um, cases and patients, and so if you get a chance to follow me on some of these, um, Social Media, um, programs, I guess, and you can hear more about this.

Speaker 2OK.

Speaker 2Thank you. Thanks, Luke.

Speaker 2OK, questions.

Speaker 2Got one here, Jason?

Speaker 2Do you want

Speaker 2Can you, can you guys please, cause this is, uh, being recorded, so if you can press that button and the green light should go on.

Speaker 3Do you

Speaker 3only do lumbar T lifts for your fusions, or do you do any lateral or a lifts Outpatient, or is it all just percutaneous T

Speaker 3lifts?

Speaker 1Yeah, you know what happened was, um, in my previous job, I didn't have access to good exposure surgeons.

Speaker 1And so I was doing a lot of work with uh spinal oncology and I learned how to become really facile doing a lot from the posterior Approach. So I feel very comfortable doing most cases posteriorly. So, uh, my procedure of choice is T lifts, and all my awake procedures are just with T lifts. I don't really do much for a lifts and laterals.

Speaker 2Look, um, so when you give a spinal, it's not an indwelling catheter. So, so what do you do about the patient or the type of case that goes beyond what you anticipated and their spinal starts to wear

Speaker 2out?

Speaker 1Yeah, so, um, two options. I mean, first and foremost, you can redose it. So if you needed to, you can just, you yourself can do the spinal or one time the anesthesiologist came in, she redosed it for me.

Speaker 1With the laminectomy it's even

Speaker 2you've done that yourself, meaning that you, she did expose the dura and then you, you actually place in the, yeah,

Speaker 1and it's easy because it's, it's with the laminectomy it's even, it's even easier, right? But with the T lift just, uh, you could redose it yourself.

Speaker 1But the Other thing is that if you, so that's just straight just trying to get yourself out of trouble.

Speaker 2Wait, so when the anesthesiologist does it, how do they, because it's a sterile field, scrub

Speaker 1in, they scrub in.

Speaker 2Oh, they scrub in, yeah,

Speaker 1she just did it once though, but we haven't, you know, the one thing I'll tell you though is that if you do want to do awake spinal fusions, um, I think it's really helpful to have predictability. So you should really get a good sense of what your OR times are, and then they can dose, they dose the spinal anesthesia accordingly.

Speaker 1Based off of time, so it shouldn't be a problem. And then if you dose it more than you need, there's no harm. There's no downside to giving more than you actually have to.

Speaker 2So you, you quoted 50% Outpatient discharge rate, so meaning that half of the patients are still kind of Inpatient. So are you just assuming then that is it like say for instance you did this in a Surgery center, so then you would need 2359 capability, right?

Speaker 1Um, yeah, but you know, the Medicare won't let you do it, so you have to keep them overnight. And then the morbidities would prevent you. So, the way I see it is that, you know, if you have a straight, healthy person, ASC, body with medical problems, hospital.

Speaker 2And then can you talk a little bit about the TLL because, um, you know, uh, I've been trying to get some of my anesthesiologists to do this, but it's not like it's not a common procedure that they learn during their training, so it's something that they have to actually either, I don't think there are even any training

Speaker 2courses for this.

Speaker 1No, and in fact, actually I'll tell you like we, because we have, we've been doing so many TLlip blocks now.

Speaker 1That we need to run a course because of that. So it's Ultrasound guided. So you first of all need um anesthesiologists who are comfortable with Ultrasound, just using it. The block itself is pretty easy to do. I mean, I don't know if you have an Ultrasound machine in the lab, but we can even just show you that um I could do my own telip blocks because of a workflow issue. We do the TLlip blocks in the preoperative holding area with the anesthesiologist while I'm closing, so that's why I don't do my own.

Speaker 1But so we do the telip block, you find the interval, it's actually easy to see between the multi fittest and longisus, and there's a couple of tricks that I've learned along the way. And it's actually kind of neat because when you deliver the Medicine, you can actually see the interval open up.

Speaker 1But I'll tell you this, is that, so we do all of our laminectomies and lumbar fusions get the Tlip block. So I, I, I have a great team of people who don't stop me from innovating or trying all my crazy things. So there's an equivalent for the T-lip block in the neck.

Speaker 1It's called the MCP block. So in a sense we're actually already, we already, I think we did MCB, uh, M as in Mary, C as in cat, P as in Paul. Yeah, I'll, I'll look up the paper for you. It was, I, I don't even know if it's been published as a paper, but there was one report, and so we started doing essentially the teallip block in the neck.

Speaker 1I did it for a patient who did a posterior cervical. Now we've only done it 3 times, so it's not, it could be all anecdotal at this point, but he started, he was using Tylenol within 48 hours after a posterior cervical. So the the equivalent in the cervical Spine has been dramatic.

Speaker 2Over there, so like, you know, when patients are under general anesthesia, like immediately post-operative, they, they feel great too, right? But like all anesthetics, they wear out. So is there a different protocol that you use when they're actually at home or during that 24 to 48 hour period plus?

Speaker 1So Experillo has been great that way.

Speaker 1So with the Experil, um, so I can predictably tell you now cause I've, um, so after Surgery, I call the patients post-op day one, post-op day 2. You have to have, when you, when you start moving towards Outpatient, I think this is what I learned from my total Hip colleagues, you have to have more touch points with the patient.

Speaker 1If you don't, they feel like they're gonna abandon you. So I'm calling them, and right now I'm in my Learning curve, so I'll call them post-op day 1 in the morning in the afternoon, post-op day 2, morning, afternoon. You will, or your staff or both. I, I do because I wanna, I wanna hear the complaints right now. Then I can pass it off to my staff once I've standardized it. So I could tell you predictably the day of Surgery, they're great. They almost have no Pain. Post-op day 1, they get a little bit of rebound, and then post-op day 2, it starts to calm down again.

Speaker 1So the key thing is that you wanna, you wanna coach them through. So then what happens is they go home, they feel great, they forget to take their Medicine before they go to bed. They wake up in the middle of the night, they have Pain, and now they're playing catch up. So if you can stop, if you can stop that process, and we'll automate this with, you know, text messaging and whatever, but if you can stop that process and not fall behind.

Speaker 1It's a comfortable experience. I have, and I'll post this. I have videos of patients who are saying 7 days or 6 days after Surgery, I stopped taking all the narcotics and just taking Tylenol. So the key thing though is that you've got to be more involved in that sense. You can't just be like, OK, great, you had your Surgery.

Speaker 2Do you know what your, uh, readmission rate is?

Speaker 1Yeah, so we've done 102 now. We have, um.

Speaker 1Uh, 3 readmissions, so 3%.

Speaker 2OK. Any Other questions?

Speaker 2Jason, do you

Speaker 3use bone stimulation?

Speaker 3Do you use bone stimulation for your patients post-op?

Speaker 1You know, I, I, I, I have to explore it. I don't, is the easy answer. Um, we haven't had too many issues with pseudos, but I think it's something I should probably explore for some of my higher risk patients. I typically don't though.

Speaker 2OK, thanks a lot,

Speaker 1Luke. OK, thank you.

Speaker 2Great talk, man.