Is awake spine surgery a wave of the future?

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Mirant Dave (left) and Richard Menger (right)

Two experts outline their views on whether or not awake spine surgery will gain significant traction over the coming years.

Awake spine surgery IS a wave of the future: Mirant Dave, spine surgeon at Stavya Spine Hospital and Research Institute (Ahmedabad, India)

Great enlightened beings and leaders are on a spree to awaken the world. Be it Save Soil, Rally for Rivers, preventing wars, or global warming, many nations have joined hands to awaken people.

Awake spine surgery is one step towards surgery with the patient under regional anaesthesia. According to Bharat Dave and Raviranjan Rai (Stavya Spine Hospital and Research Institute, Ahmedabad, India), the surgeries currently performed under regional anaesthesia include laminectomy, discectomy, endoscopic spine surgeries, minimally invasive lumbar fusion and dorsal column stimulator placement.1

Endoscopic spine surgery has the most significant indications with awake spine surgery. Ajay Krishnan, a leading endoscopic spine surgeon (Stavya Spine Hospital and Research Institute, Ahmedabad, India), believes that patients under regional anaesthesia can be tested by provocation during the endoscopic surgery with the physician looking out for unusual pain patterns. With indications of endoscopic surgery growing by the day, many spinal conditions are being treated with endoscopic and awake spine surgery.

According to experiences shared by Shivanand Mayi and Devanand Degulmadi (Stavya Spine Hospital and Research Institute, Ahmedabad, India), there are various benefits of spine surgery on an awake patient. These include: Daycare surgery, improved postoperative pain outcomes, fewer workdays lost, suitability for patients with comorbid conditions, minimally invasive procedure, less blood loss, increase in patient’s confidence to undergo surgery, awake patients can give feedback about unusual pain and patients can return to routine life sooner.

According to Vandana Trivedi (M. P. Shah Government Medical College, Jamnagar, India), many unpublished reports of spine surgeries performed under regional anaesthesia can be found in rural hospitals of India dating back more than 15 years. Indian anaesthesiologists have been using regional blocks for spine surgeries due to the lack of infrastructure in rural hospitals. Thoracolumbar interfascial plane block for minimally invasive spine surgery has promising results in the literature.2

Amita Dave, managing director of Stavya Spine Hospital and Research Institute (Ahmedabad, India), notes that regional anaesthesia, and fewer days spent in the hospital significantly reduces costs for patients. In addition, Akruti Dave (Ahmedabad, India), a leading spine physical therapist, believes that postoperative rehabilitation in patients with daycare spine surgeries provides excellent outcomes and patient compliance.

With a more significant number of patients educating themselves online, I believe that demand for awake spine surgery could be a future wave. Compared to general anaesthesia, patient compliance with regional anaesthesia would be critical in decision-making. During the minimally invasive transforaminal lumbar interbody fusion procedure, patients undergo spinal and regional anaesthetic. They often wear headphones during the procedure and listen to music, which improves their overall experience.3

I believe adequate anaesthesiologists and spine surgeon training can be accomplished, as medical professionals nowadays are open to adapting newer technologies and innovations. This technique benefits the doctor-patient relationship and more confidence in the procedure performed. Preoperative compliance and warning signs are better identified, thus creating a winning situation.

Spinal News International recently ran a poll asking physicians whether or not they believed awake spine surgery to be a wave of the future or a passing fad. The results were as follows:


Awake spine surgery IS NOT a wave of the future: Richard Menger, fellowship-trained neurosurgeon serving as director of the University of South Alabama (USA) Health Spine Institute and chief of complex spine surgery at USA Health (Mobile, USA).

Awake spine surgery is not the panacea of progress. It’s not so much a fad; it’s a tool in the toolbox. This tool harnesses the ability to have compliant and relatively healthy patients undergo awake surgery with a faster recovery and shorter hospital stay.

In short, the relative inclusion criteria are those patients who are going to do well. It targets patients who are healthy and not obese with a specific isolated fixable pathology. Patients generally have a few comorbidities and are potentially motivated to correct any health problems in order to have awake surgery. They have to be laid back and not anxious by nature. It attracts a patient who wants to get better quickly by the avenue of the least invasive way possible.

That’s a great patient population to have awake or asleep.

In neurosurgery we do certain cranial cases awake that have a distinct benefit and inclusion criteria to do so. This includes awake craniotomies for eloquent area tumour surgery and deep brain stimulation (DBS) for Parkinson’s disease. But there are criteria, and there is a distinct clinical purpose to take on that very controlled chaos. That is, the surgeon can directly test and interrogate the cortex for a maximum safe resection of a tumour, for example.

But why take that risk on during a routine prone spine surgery?

There has even been a push in certain deep brain stimulation (DBS) centres to revert to general anaesthesia for DBS surgery in the MRI suite.4  

Awake surgery can be dissected from the driving force behind it which is not a fad in any way. This is an Enhanced Recovery After Surgery (ERAS) protocol. A focus should be on early ambulation, shortened hospital stay, quicker return to work, and utilisation of opioid alternatives through a dedicated ERAS pathway. We currently utilise an ERAS protocol without awake surgery.

My patients ask about enabling technology all the time, robotics, navigation, “the laser”.  I do not advertise for it, but I have never had a patient ask about awake spine surgery. I have scrubbed awake spinal cord stimulator procedures. It’s an approach. It’s a tool. It’s a discussion.

Awake spine surgery can certainly be a vehicle for early technology adopting surgeons to develop, brand and differentiate themselves in their local market or academic pedigree. This has the potential to elevate everyone. Certain surgeons in this space are pushing the technique into the elderly population. It will be interesting to see that progress, and it’s outstanding to see surgeons committed to the field in this way. And, there are some giants in our field pushing awake spine surgery.5

But, the most pressing argument that I can’t seem to get past is a simple one; I would not want to have my spine surgery awake. Would you? Because it would include every part of the process from the tubular retractor, the gearshift, the tap, the pedicle screws, the interbody placement, to the inevitable spinal fluid leak repair.

Mirant Dave is a spine surgeon and researcher at the Stavya Spine Hospital and Research Institute (Ahmedabad, India). He was educated at B. J. Medical College (Ahmedabad, India). He is an editorial team member of Backbone: The Spine Journal and is a sub-committee member of the Asia Pacific Spine Society.

Richard Menger is a fellowship-trained neurosurgeon serving as director of the University of South Alabama (USA) Health Spine Institute and chief of complex spine surgery at USA Health (Mobile, USA). He performed his spine fellowship at Columbia University with a focus on paediatric spinal deformity.  

References:

1. Fiani B, Reardon T, Selvage J et al. Awake spine surgery: An eye-opening movement. Surgical Neurology International. 2021;12:222.

2. Ye Y, Bi Y, Ma J et al. Thoracolumbar interfascial plane block for postoperative analgesia in spine surgery: A systematic review and meta-analysis. PLOS ONE. 2021;16(5):e0251980.

3. Dyrda L. Dr. Alok Sharan performs 100th awake spinal fusion — will this be the way of the future? [Internet]. Beckersspine.com. 2022 [cited 26 May 2022]. Available from: https://www.beckersspine.com/spine/item/46379-dr-alok-sharan-performs-100th-awake-spinal-fusion-will-this-be-the-way-of-the-future

4. Harries A, Kausar J, Roberts S. et al. Deep brain stimulation of the subthalamic nucleus for advanced Parkinson disease using general anesthesia: long-term results. Journal of Neurosurgery. 2012;116(1):107-113.

5. The Spinal Surgery Getting Patients Back on Their Feet Faster [Internet]. The Spinal Surgery Getting Patients Back on Their Feet Faster | UC San Francisco. 2022 [cited 26 May 2022]. Available from: https://www.ucsf.edu/news/2022/05/422701/spinal-surgery-getting-patients-back-their-feet-faster


1 COMMENT

  1. It’s uncomfortable, to be prone for at least an hour or more, if the patient is obese than there is a severe pressure on the thorax and the pelvis, sometimes on the sexual organs, you cannot use the knee- elbow position, often regional anesthesia is interrupted or insufficient with sudden heavy pain, patient is moving, if the patient experience this electrocuting sensation after nerve contact it’s irritating. In awake craniotomy we do not use it for lesions where a prone position is mandatory and also lying of the side will discomfort after more than 2 hours…! Therefore it will work if you don’t have experienced anesthesiologists, you will keep the money by yourself, it’s a gimmicky, don’t go back to medieval times.

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