Awake Spinal Fusion—introducing the Rapid Recovery Spine Surgery protocol

BY DR ALOK SHARAN

There have been tremendous advancements in the field of spine surgery over the past few decades. The advent of newer types of instrumentation along with techniques for placing instrumentation has increased the capabilities of what can be performed in spine surgery. Less invasive techniques, along with robotics and navigation systems, have made the placement of this instrumentation safer. And finally, there has been a tremendous concentration of research on factors outside of the operating room, including the use of Enhanced Recovery After Surgery (ERAS) protocols, that have led to improved outcomes and changed the paradigm for recovery. Awake Spinal Fusion represents the next major advancement in the evolution of spine surgery.

Awake Spinal Fusion is a protocol that uses newer techniques of regional anesthesia to perform lumbar spine surgeries. By avoiding general anesthesia and using newer regional blocks, patients are able to recover safer, better, and faster after spine surgery.

The transition to using regional anesthesia vs general anesthesia has occurred in many other surgical specialties. It is very common for our hand colleagues to perform surgery with the patient wide awake. Knee replacements are routinely performed under spinal anesthesia, allowing the patients to mobilize quickly after surgery.

It has taken the spine surgery community a longer period to adopt the principles of regional anesthesia. In 1959 a publication from the Henry Ford Hospital demonstrated the efficacy of spinal anesthesia for lumbar spine surgery. (1) Since then, there have been many publications demonstrating the efficacy of axial blockade for lumbar surgeries. (2)

From lumbar laminectomy to lumbar fusion

For me the use of regional anesthesia in lumbar fusions started as a personal journey. I had been performing lumbar laminectomies using spinal anesthesia for many years when a patient with an L4–5 spondylolisthesis presented to my office. She was a widow and had been suffering from significant pain in her back down her legs. Having failed a course of non-operative treatment she knew that she needed surgery but was hesitant to proceed because of the side effects from general anesthesia. She had undergone a shoulder surgery in the past but had developed delirium for a few days after that surgery. This was consistent with the results of many studies that have demonstrated the higher incidence of post-operative delirium in elderly individuals after general anesthesia vs regional anesthesia. (3,4)

When I transitioned my practice to using spinal anesthesia for lumbar laminectomies, I had noticed that my patients had been experiencing a tremendous recovery. They were experiencing less pain after surgery, required less narcotics, and were able to leave the hospital faster. It was clear that the avoidance of general anesthesia allowed patients to recover faster.

I discussed this protocol with our patient, and she enthusiastically signed up for surgery. Using spinal anesthesia along with sedation we were able to perform a minimally invasive lumbar fusion on her. She tolerated the procedure well and was safely able to go home the next day. As we continued to transition our patients to the use of regional anesthesia, we were seeing tremendous outcomes in our patients after spinal fusion surgery.

There have been tremendous advancements in the field of spine surgery over the past few decades. The advent of newer types of instrumentation along with techniques for placing instrumentation has increased the capabilities of what can be performed in spine surgery. Less invasive techniques, along with robotics and navigation systems, have made the placement of this instrumentation safer. And finally, there has been a tremendous concentration of research on factors outside of the operating room, including the use of Enhanced Recovery After Surgery (ERAS) protocols, that have led to improved outcomes and changed the paradigm for recovery. Awake Spinal Fusion represents the next major advancement in the evolution of spine surgery.

Awake Spinal Fusion is a protocol that uses newer techniques of regional anesthesia to perform lumbar spine surgeries. By avoiding general anesthesia and using newer regional blocks, patients are able to recover safer, better, and faster after spine surgery.

The transition to using regional anesthesia vs general anesthesia has occurred in many other surgical specialties. It is very common for our hand colleagues to perform surgery with the patient wide awake. Knee replacements are routinely performed under spinal anesthesia, allowing the patients to mobilize quickly after surgery.

It has taken the spine surgery community a longer period to adopt the principles of regional anesthesia. In 1959 a publication from the Henry Ford Hospital demonstrated the efficacy of spinal anesthesia for lumbar spine surgery. (1) Since then, there have been many publications demonstrating the efficacy of axial blockade for lumbar surgeries. (2)

From lumbar laminectomy to lumbar fusion

For me the use of regional anesthesia in lumbar fusions started as a personal journey. I had been performing lumbar laminectomies using spinal anesthesia for many years when a patient with an L4–5 spondylolisthesis presented to my office. She was a widow and had been suffering from significant pain in her back down her legs. Having failed a course of non-operative treatment she knew that she needed surgery but was hesitant to proceed because of the side effects from general anesthesia. She had undergone a shoulder surgery in the past but had developed delirium for a few days after that surgery. This was consistent with the results of many studies that have demonstrated the higher incidence of post-operative delirium in elderly individuals after general anesthesia vs regional anesthesia. (3,4)

When I transitioned my practice to using spinal anesthesia for lumbar laminectomies, I had noticed that my patients had been experiencing a tremendous recovery. They were experiencing less pain after surgery, required less narcotics, and were able to leave the hospital faster. It was clear that the avoidance of general anesthesia allowed patients to recover faster.

I discussed this protocol with our patient, and she enthusiastically signed up for surgery. Using spinal anesthesia along with sedation we were able to perform a minimally invasive lumbar fusion on her. She tolerated the procedure well and was safely able to go home the next day. As we continued to transition our patients to the use of regional anesthesia, we were seeing tremendous outcomes in our patients after spinal fusion surgery.

About the author:

Dr Alok Sharan, MD, MHCDS, is an Orthopedic Spine Surgeon who is a pioneer of the Awake Spinal Fusion procedure, the latest advancement in minimally invasive spine surgery. He is a leading authority both nationally and internationally on the Awake Spinal Fusion procedure, having been invited to give presentations throughout the United States and many countries around the world. He is the President and Founder of the Spine and Performance Institute, a practice devoted to providing personalized and holistic care for individuals who suffer from spinal disorders. Dr Sharan 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.