Dr. Alok Sharan: Coronavirus, cost savings will speed adoption of awake spine surgery

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Alok Sharan, MD, was recently appointed director of spine and orthopedics at NJ Spine and Wellness in East Brunswick, N.J.

An early adopter of the spine surgery that doesn't require general anesthesia, Dr. Sharan has completed 130 cases since he started performing the procedure in 2017.

He spoke to Becker's Spine Review about how awake spinal fusion fits into value-based care and how the COVID-19 pandemic highlighted some of the procedure's benefits.

Note: Responses are lightly edited for style and clarity.

Question: How do you see your protocols for awake spinal fusion developing at your new practice?

Dr. Alok Sharan: NJ Spine and Wellness is a multispecialty, multidisciplinary spine-focused practice. The credo within our practice is to get "patients better faster." Awake spinal fusion makes so much with our  practice as we feel strongly that we are able to achieve  improved outcomes through a combination of my surgical technique along with  pre- and postoperative rehab.  

At the end of the day, awake spinal fusion is a protocol; it's not just one thing. We're looking at the patient from the moment they decide to have surgery through the whole process, including what we do in the OR, with the end goal of having them recover faster. From a preoperative perspective, at NJ Spine and Wellness, we have an excellent group of providers that include physical therapists, occupational therapists and chiropractors who work hard to take patients with initial pain to the next step quicker, whatever that may be. 

Q: How does awake spine surgery fit into the value-based era that the industry is continuing to move toward?

AS: If you do an apples-to-apples comparison of awake spinal fusion versus traditional fusion, it's about a 10 percent cost savings. That's not that significant of a cost savings, but for awake surgery we're able to discharge the patient the same day. The cost of a hospital stay  is very variable; anything from $2,000 to $4,000. If you add this cost savings, then we start to see some real savings.   If you do this surgery at an ASC it's about 50 percent of the cost of doing it at a hospital. Although the total direct cost savings is about 10 percent, when you perform the procedure at an ASC the cost savings would be tremendous. I think that awake spine surgery will be the enabler to do these procedures at the ASC. That's where the real cost savings will come in. 

Q: Why do you think this procedure has been more widely adopted overseas than in the US?

AS: We learned the risks of intubation during the pandemic. I think there are patients who were intubated during COVID or were at risk of intubation who want spine surgery without being intubated. We're actually seeing a few patients being referred to us now for exactly that reason — they need surgery and want to avoid intubation, or general anesthesia. 

Outside the US where resources are limited there is a tremendous risk and cost to intubating a patient. If you intubate a patient who has COVID, then the anesthesia machine is taken out to be cleaned, which is a big cost. I recently got a call from a surgeon in Egypt about this issue. In Egypt and similar countries, they want to do spine surgery without intubating the patients because they don't have enough anesthesia machines to remove from circulation. 

A similar situation is occurring in the U.S. I recently started working in a hospital in New Jersey that has adopted our awake spine protocols. There was a patient who needed spine surgery who recently had COVID. The anesthesiologist wanted to avoid intubation and adopted our awake spine protocol for this particular patient.   

Q: What challenges have you run into with payers for this procedure?

AS: I've had conversations with a couple of chief medical officers for payers. Like everything else, the first time they hear about it, there is initial hesitation. One particular payer I asked for authorization for an awake spinal fusion and there was that hesitation. I told them to come back to me three months after surgery when the episode is completed. We compared the cost of my surgery to what they traditionally authorize. The cost savings was so significant that we started looking at how we could do this more often. Not only did the patient go home the same day, but he didn't require many pain meds and his rehab was limited, so the overall episode cost was much smaller. Our goal is to improve those results all the time.

Q: Do you see awake spine surgery becoming more prominent in the outpatient setting over the next five years?

AS: In the next five years, my hope is that 80 percent of patients who undergo spine surgery will be done with the awake spine surgery protocol, when appropriate. I think the COVID-19 pandemic will only accelerate this adoption. Now, we have to start thinking even harder than before about how to save costs while achieving great outcomes. As a spine surgeon, how do you save money? You can reduce implant costs of course, but there's no question that going to a cheaper site of service like the ASC would be better. 

Q: How does the conversation with patients typically go when recommending awake spine surgery? 

AS: Naturally, patients don't want to be awake for surgery. I tell the patients that it's more like they're in a twilight zone, than actually awake. But I also explain the benefits of doing the surgery without intubation. They can wake up after surgery and avoid the sore throat, nausea, vomiting and constipation. 

A lot of the risks of surgery come down to general anesthesia and COVID highlighted these risks. We eliminate a lot of the procedural risks by not using general anesthesia or intubation. Of course there are risks of surgery in general and spine surgical risks, but by reducing some of these risks we're performing a safer procedure, which the patients appreciate.

Q: How has your virtual study group for awake spinal fusion progressed through the pandemic?

AS: We were planning to have an awake spine surgery course in Seattle before COVID hit. Unfortunately that course had to be canceled so we pivoted. As a result, we set up an online learning platform called doc.social. We realised during the pandemic that surgical education has to go digital. Doc.social allows surgeons to develop courses online so other surgeons can view them. We're getting ready to launch the awake spine surgery course on this platform. There is also a section on how to create a study group around your course.  

We have about 10 spine surgeons who are part of the study group for awake spinal fusion, including surgeons from India, Italy and soon England. We met online and shared our protocols and case discussion. As a result, surgeons have taken that information from the study group — surgeons in Colorado, Tennessee and North Carolina — and mixing and matching it to their patient population. Now we're trying to figure out what type of outcomes we should start collecting, so we can really show the value of this procedure. 

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