Spine surgery the patient's way: Dr. Ernest Braxton on awake procedures

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On February 17, Ernest Braxton, MD, of Vail (Colo.) Summit Orthopaedics and Neurosurgery performed a landmark spinal fusion in the state.

His patient was a 68-year-old woman. She wanted to have 1970s classic rock playing in the operating room, and she could make that call because she was awake for the surgery, Dr. Braxton said.

It was the first awake robot-assisted transforaminal lumbar interbody fusion done in Colorado, and Dr. Braxton spoke with Becker's about the case and how he sees awake spine surgery developing.

Note: This conversation was edited for clarity and length.

Question: What made this case particularly innovative? What were the biggest challenges getting it done?

Dr. Ernest Braxton: What's innovative about it is we're incorporating the next generation of computerized surgery on an awake patient. The point of using the robot is that it makes outcomes more reproducible. It also makes the operation safer because you're using the targeting accuracy solution from the computer when placing pedicle screws. Basically, all the robot does is provide a computerized drill guide to place pedicle screws, which is a big part of any spine stabilization operation in 2022. The main challenge in using the robot on awake patients is that the plan is based on an intraoperative X-ray plan. If a patient moves during surgery, that X-ray plan is no longer valid. Getting an awake patient to hold still during the procedure so that we can safely perform the surgery was a big challenge.

Q: What were conversations with the patient like? How on board were they initially with the idea of an awake surgery?

EB: The patient was actually very interested in having the surgery done awake. The biggest reason is they had anesthesia in the past, and they felt hungover after the operation. They felt like their executive function and memory was impaired, albeit only for about three to four weeks, but they felt really impaired for several weeks after the surgery.

The other factor is the patient gets a more respectful, patient-centered experience, so the experience is totally different when you're awake. The music we listen to in the operating room is what the patient wants, not what I want. We talk during the operation, and the patient knows that I'm doing the surgery, not one of my assistants. They get that kind of continuity and respect that they deserve when they're awake. In other words, if the patient is awake, we're not talking about the next surgery we're going to do or the last surgery we did or what we're going to do on the weekend. We're focused on this case. I think you kind of forget that there's a person in the room when they're asleep, but when they're awake, it's a more respectful environment.

Q: How do you see awake spine surgery advancing in the next five to 10 years?

EB: I see it becoming more and 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 anesthetic. 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 kind of 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 COVID-19 pandemic has put a spotlight on the need to reserve hospital beds for the sickest patients. Fortunately, COVID-19 cases are decreasing in our community, but we still focus on minimizing the hospital stay. Anything 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.

Q: What other spine technologies are you excited about?

EB: I'm really excited about the next-generation Remi robot that we just purchased from Accelus, and it's designed specifically for the ASC. It's kind of like the evolution of the cell phone. The robot that we used in our first case has a very large footprint and is very heavy. It can't be transported to other campuses and is quite expensive. The new generation robot that we just bought is much smaller and weighs about five pounds. It's mounted to the surgery table, and it's portable. It has a much smaller footprint and is designed for the surgery center.

Q: What's going on at Vail Summit Orthopaedics and Neurosurgery in terms of growth and development?

EB: We recently merged with Alpine Orthopaedics in Crested Butte, Gunnison and Telluride, and now they're a part of VSON. We're looking at expanding into other mountain areas such as Winter Park, to provide care throughout Colorado.

We're steadily growing our practice at VSON, mostly in Colorado ski towns. We are upgrading our MRI capabilities at one of our offices, and we've recently hired a few new partners to help address the demand we have created.

What we're seeing is a great migration of folks from urban areas to our mountain communities. As a result, we are having some more pressure on our school system and increased housing prices. But there's also a demand for healthcare, from patients newly arrived from urban areas. We get a lot of folks from cities like Chicago, Los Angeles, Dallas, Houston, all buying properties and moving. People are either buying a second home, or permanently moving up here as our workforce becomes more remote. So we're trying to keep up with that population growth and offer high quality of care for these new people in our community.

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