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Can You Have a Spinal Fusion While You are Awake?

While traditional spinal fusion surgery is considered to be an extensive procedure, requiring general anesthesia and a hospital stay, Awake Spinal Fusion is a minimally invasive procedure. Instead of a lengthy hospital stay, you're up and about in just a few hours.

Dr. Alok Sharan discusses this innovative technique that eliminates a number of disadvantages associated with traditional spine surgery and allows for quicker overall recovery.
Can You Have a Spinal Fusion While You are Awake?
Featuring:
Alok Sharan, MD
Dr. Alok Sharan is an Orthopedic Spine Surgeon who focuses on minimally invasive spine surgery as well as cervical spine surgery. He is also one of the early adopters of the Awake Spinal Fusion procedure. Currently, he serves as the Co-Director of the Westmed Spine Center. He performs Awake Spinal Fusion at St. John’s Riverside Hospital’s Dobbs Ferry Pavilion.

After obtaining his undergraduate degree at Boston University he received his MD degree from the University of Medicine and Dentistry of NJ. He completed his orthopedic residency at Albany Medical Center and a spine surgery fellowship at NYU-Hospital for Joint Disease. He was named an AO Spine Fellow and an AAOS Washington Health Policy Fellow. In 2015 he completed a healthcare management degree at Dartmouth College titled Masters in Health Care Delivery Science.

Previous to WestMed he was Chief, Orthopaedic Spine Service at Montefiore Medical Center.

Committed to providing the community with high-quality spine surgical care, he has been recognized as a Best Doctor by Castle Connolly, New York Magazine Best Doctor, along with Westchester Magazine Best Doctor.

He has received numerous academic distinctions for his research with over 100 publications, abstracts, and book chapters. He has co-edited a textbook entitled Basic Science of Spinal Diseases. Dr. Sharan currently serves as a Deputy Editor for the publication Clinical Spine Surgery.
Transcription:

Melanie Cole (Host): The growing trend towards minimally invasive back surgery has resulted in reduced recovery times and fewer complications and less risk for many patients. But did you know, that in some circumstances, you can actually be awake during this procedure? My guest is Dr. Alok Sharan. He’s an orthopedic surgeon and the Co-director of the West Med Spine Center and a member of the medical staff at St. John’s Riverside Hospital. Dr. Sharan let’s first talk about spinal fusion and what conditions might even require that discussion.

Alok Sharan, MD, MHCDS (Guest): Sure. First of all, thank you for having me. Spinal fusion surgery unfortunately to some degree comes on because of just the normal wear and tear as we are getting older. What happens sometimes is that patients or people as they get older develop degeneration in their spine and their disks. They develop bone spurs. Some people can even go on to develop bone spurs that lead to an instability in the spine where some of the bones are out of place. When you have an instability in your spine, we stabilize your spine through performing a surgery called spinal fusion surgery.

Melanie: So, what had typically been the case for spinal fusion? How has it been done in the past?

Dr. Sharan: Traditionally, spinal fusion surgery, when done for the right patient has been a successful procedure. But for many patients, using the traditional let’s say an open technique, patients will stay in the hospital for three or four days. The recovery time can extend from four to six weeks up to three months sometimes. Now we are sort of advancing our surgical techniques using a lot of novel, minimally invasive approaches using a microscope. Now we are able to do the same type of surgery just using a smaller incision.

Melanie: So, minimally invasive is a term that not everybody really understands. Speak about minimally invasive. What does that mean? What are the benefits for the patient?

Dr. Sharan: In a traditional sense, open surgery requires making a long incision that gives you big exposure to the area that you need to operate on. Nowadays, we are able to use tools such as an x-ray machine, smaller incision, and other navigation type tools that help us get to the area of the spine that we need to work on without requiring the big open incision. So, basically what minimally invasive surgery is, is using a smaller incision, using more precise tools to do the same amount of work, that is resulting in overall less morbidity for the patient and a faster recovery.

Melanie: And now let’s talk about this term awake fusion. People think oh my gosh an awake surgery? Tell us what this is like for the patient and how do you do an awake fusion?

Dr. Sharan: Sure, thank you. So, maybe five or six years ago, I started doing minimally invasive spinal fusions and when I started doing them I started realizing how fast the recovery can be. I think across the country, when people have lumbar fusions, the recovery was about three to four days in the hospital and when we started doing it minimally invasive, I saw that patients were up and walking quicker and they are leaving the hospital about in a day or two. But then we started doing a lot of our other spine surgeries under local anesthesia using spinal anesthesia and what we realized is that often if we can just numb the patient from the waist down and do our procedure, the patient wakes up faster and the recovery is quicker because we can avoid general anesthesia and all the gas in your body. So, we have been doing awake laminectomies which is a smaller procedure for a while. I think it was after 100 or 200 cases of doing the awake laminectomies that we said why don’t we try the same anesthetic technique for our lumbar fusions and see what kind of results we get. And so, as a result now, our routine practice is that if someone needs a spinal fusion surgery; we bring them inside the operating room, we give them a spinal, which is essentially numbing them from the waist down. We ask the patients to actually position themselves on the OR table for us. We ask them how sleepy they want to be versus how awake they want to be. If they want to be sleepy, we will give them some medicine just to let them take a good nap. If they want to be awake, we give them headphones and music and we perform our surgery. And the surgery only lasts about an hour or two hours at most and as soon as we are done with our surgery, the numbing medicine wears off, the patient is able to wiggle their toes and move around and by the time they get to the recovery room; and a couple of hours after that, we have them pretty much up and walking the same day.

Melanie: Wow. That’s incredible. It really is. So, how scary is the thought of this for patients and are there certain people for whom this is not an option?

Dr. Sharan: You know it’s actually really interesting because when we first started doing this, we thought that patients would be hesitant to be awake and whatnot, but I think more and more, what I have really realized is that a lot of times people will avoid having surgery in general because they have a fear of losing control. When someone else is putting you to sleep and for a couple of hours if you don’t know what’s going on; there is a tremendous anxiety around that. What we are finding now is that because patients are not going to sleep, they are in control; that anxiety that they have is gone and you can see that after our surgery patients are just very calm. In fact, we feel that we have done a good job of not only doing a good spine surgery, but the patient saying that I feel like I was in a spa. And nowadays, people are just saying that they have a good nap, if they listen to music. What we have really been trying to do is redefine the whole surgical experience so that people are not losing control, they will listen to music and they come out and say wow, I feel great. This is much better than I expected.

Melanie: How do you keep them from moving around?

Dr. Sharan: Well the key thing is two things. One is that we are giving them a spinal. And so, by giving them a spinal, essentially, they are numb from the waist down, so they just can’t move around. Second of all, we actually want them to move around a little bit because what we have noticed is that oftentimes when patients are having spine surgery, they may be face down and their shoulders can be in an awkward position and I don’t know about you, but I know that as people get older, their shoulders begin to hurt them and so it’s natural that you want to actually move your shoulders around. So, during the surgery, we will have the patients actually we will ask the patients are your shoulders okay, do you want to move around. And very slightly, nothing dramatic, we will have the patients actually reposition themselves and I think what that does is when they wake up, or when they are done with the surgery, they are less likely to have shoulder pain. They are more likely to be comfortable. It’s like having a good nap. That’s the experience that we are trying to create.

Melanie: Well who doesn’t love a good nap Dr. Sharan? However, are there some benefits that people might not realize for you the surgeon? It would seem that you might prefer people asleep so that you can do your job, however, you are preferring that they are awake. Is there a reason for that? What are the benefits for the surgeon?

Dr. Sharan: So, for me, the biggest benefit is what I notice is that patients who have general anesthesia, because there are times when we do it; when they wake up they are a little bit more confused, they are not with it. That just leads to a prolonged recovery process. I really like the fact that the patients are awake because as soon as we are done with surgery; it’s almost like they never had any kind of surgery at all. I can talk to them. I can get feedback from them. I can see how they are feeling. They can respond. What’s so different is that normally when you think about having surgery; it’s a one-way process meaning that the surgeon is in complete control and he can do whatever he wants. That’s a benefit of the patient undergoing general anesthesia. But in this day and age, as patients are becoming more engaged, they want to be part of the process. So, what I really like is that by keeping the patients awake, by not making them too sleepy; they can tell us, yes my should is hurting, let me just move a little bit or after the surgery is done, they are fully awake and they say yes I think I’m feeling good or I’m not feeling good I need this medicine or that, but it is just allowing the patients to sort of be engaged in a process which they normally were not engaged in.

Melanie: What a wonderful description of that and the benefits for you as a surgeon and since this is a fusion, what is life like as far as movement capabilities for the patient after surgery such as this?

Dr. Sharan: Well this is the most remarkable thing is that there are patients who are just bouncing back much quicker than expected. Because the reality is this, when you first think about the thought of a spinal fusion; you would think that you would be immobilized because we are gluing the bones together, you can move. But I find actually, that the patients are doing much better and the reason being is that when they are not fused; they have an instability such that when they move, that instability let’s say pinches on the nerve and gives them more pain. But when we stabilize them; they no longer have that instability which allows them more freedom of motion and so what we are seeing now is that these patients are actually bouncing back quicker. They are returning to work faster and they are just getting back to the life that they want to have much quicker than we expected.

Melanie: Dr. Sharan, wrap it up for us with your best advice, questions that you would like patients to ask you if the discussion of spinal fusion comes up and what you want them to know about awake spinal fusion and awake surgeries in general.

Dr. Sharan: Well I think that as the population gets older, the unfortunate truth is that many more people may require spine surgery. That is just part of the wear and tear process. And so, as more people require surgery, the question is going to be what’s going to be the overall best way to have your surgery and I’m not saying that general anesthesia is bad. There is going to be times when you will need to have general anesthesia, but if you are fairly healthy, fairly active and looking to bounce back quicker; having your surgery done under local anesthesia, having awake spine surgery may be an option that can get you back to work as quick as possible. At this point now, a spinal fusion surgery across the country, people stay in the hospital for about three or four days, but we are at the point now where about 25% of our patients are undergoing a spinal fusion surgery and going home the same day. I think that for those people who want to be active as soon as possible but they are debilitated with their pain; the awake spinal fusion is an option for them that can help them get back to the life that they want to have.

Melanie: Really a fascinating topic Dr. Sharan. Thank you so much for joining us today and sharing your expertise explaining this awake spinal fusion and what patients can expect. Thank you again. You’re listening to Riverside Radio HealthCast. For more information please visit www.riversidehealth.org, that’s www.riversidehealth.org. This is Melanie Cole. Thanks so much for listening.