Becker's Spine Review

14 SPINE SURGEONS Dr. Alok Sharan performs 100th awake spinal fusion — will this be the way of the future? By Laura Dyrda A lok Sharan, MD, co-director of the Westmed Spine Center in Yonkers, N.Y., began performing awake spinal fusions in 2017, and has just reached a mile- stone: 100 successful awake spinal fusions performed. During the minimally invasive transforaminal lumbar interbody fusion procedure, patients are put under both spinal and regional anes- thetic. ey oen wear headphones during the procedure and listen to music, which improves their overall experience. Over time, Dr. Sha- ran built a protocol that prepares patients for surgery to return home within 24 hours of the procedure. e 100th patient was a 63-year- old who returned home the same day. "As a doctor, it's a tremendous accomplish- ment to perform 100 awake spinal fusions because we took one operation, spinal fusion surgery, and transformed the experience," said Dr. Sharan. "My conclusion is that awake spinal fusion is the next iterative advantage in minimally invasive spine surgery. It's an en- hanced recovery protocol that in my mind, when you do it, leads to less pain, faster mo- bilization and an overall quicker recovery." So far in 2019, around half of Dr. Sharan's pa- tients are discharged home the same day, with an average length of stay of 0.8 days. e pro- cedure has also been effective in lowering nar- cotic use postoperatively; around 60 percent to 70 percent of the patients don't require narcotics a week aer surgery. ese results show awake spinal fusion could be an ideal procedure to achieve the goals of value-based care. Commer- cial and government payers are now challeng- ing healthcare providers to improve quality and lower costs for the 90-day episode of care, not just the surgical procedure. Value-based care also takes the patient experience into account. "You can't make spinal fusion surgery a better experience by thinking about just what hap- pens in the operating room," said Dr. Sharan. "It's about educating the patient properly, doing a proper risk assessment of the patients to un- derstand how to optimize them before surgery, and making sure they understand all aspects of the procedure prior to surgery. You want them to engage with your nurses at the hospital and buy-in to following your protocol." Consistent messaging across all nurses and staff members will help patients set the right expectations for surgery. When surgeons in- tend for an outpatient procedure, everyone involved should continue to reiterate the plan to ensure the patients return home the same day. e surgeons should also be prepared to increase touchpoints with patients aer they return home so they don't feel abandoned during the process. Dr. Sharan isn't the only surgeon performing awake spinal fusions; other surgeons around the country have adopted the technique as well. "My goal is to personally understand how to optimize the patients better and refine the criteria for patients who are good candi- dates for outpatient fusions," said Dr. Sharan. "At some point, we'll partner with a company or organization that can help us gather good scientifically balanced evidence around this, which will lead to cost-effectiveness. en we will need to create an alternative payment model that incentivizes surgeons to perform procedures using our awake spine surgery protocols. Increasingly there will be a greater need for spinal fusions in the future, and if we can find a more cost-effective way of per- forming them, we can get payers on board." n 2 neurosurgeons discuss how spine can be more cost-effective By Alan Condon Two professors of neurosurgery weigh in on how cost-ef- fectiveness can be improved in spine. Question: Do you have any theories as to how cost-ef- fectiveness in spine can be improved? Raj Narayan, MD. Professor and Chairman of Neurosur- gery at Zucker School of Medicine at Hofstra/North- well (East Garden City, N.Y) and Director of the North- well Health Institute of Neurology and Neurosurgery (Manhasset, N.Y.). There are several options — none of which are likely to be popular with the surgeons: (1) bun- dled payments for the surgery and the implants; (2) at-risk contracts for large employed groups; (3) uniform reim- bursement regardless of the number of levels done; and (4) some portion of the payments being linked to patient satisfaction. However, each of these strategies could, and likely will have unintended consequences. James Harrop, MD. Professor of Neurosurgery at Thom- as Jefferson University Hospital (Philadelphia). I think another way to approach this question is how do we im- prove and maximize the value of spine surgery. Since val- ue equals quality/cost, you can either cut costs or improve quality to get increased value. We as spine surgeons need to better understand how to maximize our patient out- comes. There has been great work on this in terms of out- come measures and better defining patient populations but more needs to be done. n

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