Dr. Vijay Yanamadala on 2 years of awake spinal fusion

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Vijay Yanamadala, MD, performed his first awake spinal fusion in October 2021, and almost two years later he's thinking about the next move for his practice.

Dr. Yanamadala, of Hartford (Conn.) HealthCare, spoke with Becker's about his progress with the awake surgery program and shifting spine cases to the ASC.

Note: This conversation was lightly edited for clarity.

Question: This year you'll be marking two years of performing awake spinal fusion. How has your technique evolved in that time?

Dr. Vijay Yanamadala: First and foremost, I'm so lucky to work with a very forward-thinking anesthesia team here at Hartford HealthCare. We had never contemplated doing a spinal fusion right before this. But, prior to doing the spinal fusion, we did a number of laminectomies awake. Part of the preparation for this was making sure that they're comfortable with spinal anesthesia, which they were, because a lot of our joint surgeries are being done under spinal anesthesia. We also made sure that the team is comfortable doing smaller surgeries. I still do a lot of my laminectomy discectomy under spinal anesthesia as well. Those were surgeries that I had done prior to doing the awake fusion to get people comfortable. Once we did the fusion, then everyone became more comfortable with the workflow. 

We know that these cases have a time limit. So you really want to get from beginning to end within three hours. And so that requires all the team members to just understand the workflow and and really be efficient and and get things through. The first awake spinal fusion patient of mine who was 82 at the time, is now two years out. I still continue to follow up with her, and she's doing very well. She really had very poor functional status before this. But she continues to do well now two years out from surgery.

Q: In a past interview you discussed outpatient spine surgery and moving more cases to the ASC. Are there any updates on that shift?

VY: So I routinely do awake spinal decompressions in the ASC. But the awake fusions I have not yet gotten home the same day. I'm usually doing a 24-hour observation, and the main reason is older patients, especially people in their 70s and 80s. I just want to make sure that they're fully mobilizing and that they're comfortable at home. I know others are actually doing the awake spinal fusions in the ASC, and I may transition soon. But I want to make sure that we have enough experience under our belt before we get there. 

Q: So it sounds like you have a timeline for this?

VY: I think it's all about our team getting comfortable with the same-day discharge. I think building that process in the right way because the last thing we want is for someone to go home on the same day and then they don't feel quite like they were ready for it. That's what I'm trying to avoid in this whole process, especially when we're starting a new program like awake surgery. The last thing you want is a bad outcome to hinder the progress that we've been making.

Q: How worried are you about reimbursement pressures affecting access to awake spine surgery?

VY: I think it's a reality that we'll have to contend with right now. To be honest, I feel like it's not something that I see immediately impacting it. But I think as payers, health systems and patients all see the benefit of it, we're going to have to constantly rethink how we do it. I think there's going to be continued and increasing demand from patients. I see this every day when more and more patients come to me asking about avoiding general anesthesia, about awake surgery. And I think there's going to be pressure from patients to make sure that we do not limit access to awake spine surgery going forward.

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