Awake spine surgery has largely been limited to shorter, simpler procedures, but Stanley Hoang, MD, of Ochsner LSU Health in Shreveport, La., has leveraged the technique in new ways.
Dr. Hoang, who performed the world’s first awake spinal fusion using a dual approach, spoke with Becker’s about the achievement and what’s next for the technique.
Note: This conversation was edited for clarity.
Question: What’s the story behind this newest awake spine surgery milestone?
Dr. Stanley Hoang: As people get older, they become more sick, and they require more complex spine surgeries. And at the same time they have other issues with their hearts and lungs, and they’re not the best candidate for surgery. Over the last 10 years or so, people have been trying to do more awake spine surgery to take into account these risk factors.
When you’re awake there’s less stress in your heart and in your lungs so they can tolerate more complex surgery. You’ll see awake surgery for cases like discectomy, decompression and some fusions. We also have lateral approaches.
With awake surgery, you only have about three hours or so before the anesthesia wears off. Typically for awake surgery, people go under spinal anesthesia, and they get paralyzed for three hours or so then the anesthesia wears off. So you can’t do anything that’s more than three hours like a complex spine surgery. People mostly stick to doing spinal fusion at one level or so, and I thought I needed to find a way to do more complex spine surgery under three hour limitations.
The prone lateral approach is a newer thing where you open the side and put in the screws. Usually that’s a two-stage process where you go through one side first and then have to turn the person around. I’ve been doing pro lateral surgeries, and I saved a lot of time and could bring that down to three hours or so. So, I thought I could apply this to awake surgery.
Q: Are there any spine procedures that you think are well positioned to grow with awake spine surgery?
SH: People have pathology at multiple levels, so the future would involve doing multi-level fusions and even more complex spine surgery. Our goal is to try to get things done very quickly, and efficiently in as little as three hours.
Q: Other awake spine surgeons have emphasized the importance of strong protocols for success. What have been the most effective protocols and procedures that you’re doing?
SH: It’s very important to think about before and after surgery. We have a mix of some newer medication and even some Tylenol. After that, we have a protocol for pain controls. We use some NSAIDs and some opioids. That helps to actually allow them to get up quicker and go home earlier. So we try to minimize opioids and use other medications for pain control. With the pain control protocol, we can really optimize the stay.
Q: Reimbursement remains a hurdle for physicians everywhere. Have you faced many obstacles with awake spine reimbursement or costs?
SH: The payments are the same, but I think in terms of anesthesia and the hospital stay, if patients can avoid general anesthesia and a multi-day stay, it can cut the cost down significantly. And in the future we can do more complex spine surgery in an outpatient setting, so I think it’s a great help with healthcare costs if we can do this more consistently, efficiently and safely.
Q: What do you envision for awake spine surgery five years from now?
SH: The main thing is patient education. They don’t want to be awake. There’s a lack of education. I think in the future we can promote this more, and people will be more aware of this, and understand that awake spine surgery isn’t a bad thing. It’s putting less stress on the heart and patients can go home earlier.
