Becker's Spine Review

25 THOUGHT LEADERSHIP What's next for awake spine surgery? 3 predictions By Alan Condon A wake spine surgery avoids general anesthesia and in- tubation and uses a local anesthetic to let surgeons ex- amine a patient's neurologic condition during surgery. Benefits of awake spine surgery include faster recoveries, improved pain control and reduced postoperative nausea. It also eliminates the need to use intravenous narcotics and reduces the cost of stay. Only a handful of spine surgeons are currently performing the technique in the U.S. Three of those surgeons discussed how awake spine sur- gery will evolve in the coming years: Note: Responses were lightly edited for style and clarity. Vijay Yanamadala, MD. Hartford (Conn.) Healthcare: I think that 10 years from now we're going to see awake spine surgery being done in the majority of cases. Patients will demand it. I think payers will also push in that direction, and we as surgeons will come to see its benefits, too — not only for our patients, but for our processes and ourselves. As it becomes more popular, the processes will be developed, and it will be smoother for broader adoption. Ernest Braxton, MD. Vail (Colo.) Summit Orthopaedics and Neurosurgery: I see it becoming more commonplace as patients demand a better experience with surgery, in the same way that we have seen regional anesthesia become very commonplace with total knee and total hip replacement surgery. My mom recently had her knee replaced. It was performed with similar regional anesthesia blocks and a spinal an- esthetic. She was awake for the operation, and she went home the same day after surgery. I have been applying this technique in my surgeries, and other surgeons around the country have adopted regional anesthesia for spine surgery. What I'm really seeing is that the COVID-19 pandemic accelerated that growth because of a greater desire for the patient to be at home and out of the hospital. The hospital tends to have sicker patients. Outpatient surgery keeps beds available for higher-acuity patients, which has become extremely important. The pandemic has put a spotlight on the need to reserve hospital beds for the sickest patients. Fortunately, COVID-19 cases are decreasing in our commu- nity, but we still focus on minimizing the hospital stay. Any- thing we can do to accelerate recovery is worth considering. This patient stayed overnight and was discharged first thing in the morning. However, about 30 percent of my patients undergoing spine fusion go home the same day. Alok Sharan, MD. NJ Spine and Wellness (East Bruns- wick, N.J.): I believe that regional anesthesia techniques in spine surgery will allow for faster recovery. A lot of the success of awake spine surgery has come from the adop- tion of these regional anesthetic techniques. For hip and knee replacements, regional anesthesia has been a game-changer. I am very excited about how these tech- niques will impact spine surgery. n systems that show time and time again reduction in radiation, length of stay and overall complication rates. e future for AR is very bright, and systems will soon incorporate similar planning soware that will allow surgeons to expeditiously complete surgical intervention with AR headsets following a largely automated plan for perfect screw trajectory placement, disc space preparation for fusion and interbody cage placement. is could all be offered at a lower cost than when a robotic arm of any kind is added. Competition will fuel improvements for both technologies, and combining them will truly change the game of spine surgery. We have shown this already in spring 2021 when I combined Mazor X and xvision from Augmedics in the same case and I cannot tell you how incredibly efficiently and accurately this combination helped me with speed and agility in the operating room. ere will truly be a symbiotic relationship between these two technologies soon. I cannot wait! Peter Derman, MD. Texas Back Institute (Plano): An ideal system would actually incorporate both. e robot would provide stabilization and guidance, while the AR would allow the surgeon to "see" the spine without having to look up at a navigation screen, depend on fluorosco- py or perform open surgery. We are just scratching at the surface of what these technologies will enable us to do. Implant placement is only the beginning. In the future, I anticipate that MRI data will be incorporated as well so that AR and ro- botics will be able to facilitate decompressions. ese tools will become a platform for enabling all spine surgeries. I'm particularly excited about the integration of AR and robotics with endoscopic spine surgery. Isador Lieberman, MD. Texas Back Institute (Plano): Robotic technology is currently more versatile than the first-generation AR technology. Within the next five years all the proprietary spine surgery platforms will include AR modules, navigation modules and robotic guidance components. is will provide the surgeon with a compre- hensive toolbox. Lali Sekhon, MD, PhD. Nevada Neurosurgery (Reno): I'm not sure AR is much ahead of robots, which are fancy guidance arms. AR puts the LCD screen in our glasses. at's about it. Both rely on navigation to power them and it's navigation I really want. Given the COVID-19 pandemic/loss of staffing, my wishlist is a little more holistic: 1. Regular operating room crew 2. Enough staff in the OR so we can do long lines and add on cases 3. Enough staff in our offices so we can function effectively 4. Enough nursing staff so patients don't sit in recovery all night or cases get cancelled e pandemic has thrown hospital and office staffing into arrears and the practicalities are that our basics are being undermined. Not enough office staff, not enough nurses, lowered reimbursement, insurance companies still fighting us. ese are my needs. AR/robots are wants. Navigation is the jewel. Navigation means I have a wonderful iPhone, but perhaps not the latest one. Give me enough staff, operating room time and hospital beds instead of AR and robotics. n

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