Vijay Yanamadala, MD, of Hartford (Conn.) Healthcare is five years into performing awake spine surgery, and he says its future includes increasingly complex cases and a greater range of patients.
Dr. Yanamadala shared the biggest transformations he’s seen in his awake spine surgery work and what’s ahead.
Note: Responses were lightly edited for clarity.
Question: In the last five years, what has been the biggest improvement you’ve made in your awake spine cases?
Dr. Vijay Yanamadala: The biggest improvement has been refining our anesthesia protocol. When we brought awake spine surgery to Connecticut nearly five years ago, we were learning from pioneers like Alok Sharan, MD, in New York, Michael Wang at University of Miami, and the UCSF group who had been doing this work. We adapted their techniques and developed our own combination of spinal anesthesia with targeted nerve blocks — which became the first use of that specific protocol combination in our region.
Over time, we’ve learned to better stratify patients. Early on, we were more conservative about who could tolerate the procedure. Now we’ve safely performed these on patients ranging from 30 to 94 years old. The key improvement has been understanding that patient motivation and selection matter more than age or even many traditional comorbidity markers.
We’ve also dramatically improved efficiency. Our operative times have decreased as our team from surgeons, anesthesiologists and OR staff, became more coordinated. That learning curve was real, but now these cases flow as smoothly as traditional approaches, often with better outcomes.
I am ever grateful to our amazing anesthesia team, Theresa Bowling, Vlad Frenk and Integrated Anesthesia Associates for pushing the boundaries of what we are able to do for our patients. It is thanks to their efforts that we were able to get this program off the ground and also make the progress we have made in the past five years.
Q: How have you seen case type change in your awake spine surgery work? Are there any procedures that you see becoming more prominent as awake procedures?
VY: Initially, we focused exclusively on single-level decompressions, laminectomies for stenosis and straightforward cases with clear indications. The awake fusion we performed in 2021 was significant because it demonstrated we could safely bring this more complex procedure to our patient population in Connecticut.
Now we routinely perform both decompressions and single-level fusions awake. The case mix has shifted. We’re seeing more complex stenosis cases, patients with grade I spondylolisthesis requiring fusion, and younger patients who simply prefer to avoid general anesthesia even when they could tolerate it.
Looking ahead, I think we’ll see minimally invasive interbody fusions become more common in the awake setting. The technology for endoscopic and tubular approaches continues to improve, and these techniques pair naturally with awake protocols. I also anticipate growth in revision decompressions patients.
The real shift has been philosophical. When we started, awake spine surgery was reserved for high-risk patients who couldn’t tolerate general anesthesia. Now it’s becoming a preferred approach even for healthy patients who recognize the benefits of avoiding intubation, faster recovery and reduced systemic stress.
Q: What does patient access to awake surgeries look like currently? How are you tackling any challenges in payer coverage, patient awareness, etc.?
VY: Patient access remains a mixed picture. On the payer side, we haven’t encountered significant coverage issues because the codes are identical. A lumbar fusion is a lumbar fusion regardless of anesthesia type. In some ways, payers should prefer awake approaches given the lower complication rates, reduced hospital stays and decreased need for postoperative monitoring.
The bigger challenge is awareness. Most patients don’t know awake spine surgery exists as an option. When we mention it, we often hear, “Why didn’t anyone else tell me about this?” That tells me there’s an education gap among referring physicians and even within spine surgery communities.
We’re tackling this through several channels. First, patient education materials that explain the option clearly without overselling it. We’re transparent that not every patient or every procedure is appropriate. Second, we’re working with our primary care network and pain management colleagues to increase awareness so patients hear about it earlier in their treatment journey.
The other barrier is surgeon availability. Most spine surgeons haven’t trained in awake techniques or don’t have anesthesia teams equipped for these protocols. That creates geographic access issues. Patients shouldn’t have to travel long distances for this option, but currently many do.
Hartford Healthcare’s investment in developing this program has been crucial. Having administrative support, anesthesia expertise and a multidisciplinary team makes these cases possible. That infrastructure isn’t universally available yet.
Q: How do you predict awake spine surgery will evolve in 2026 and then in the next five years?
VY: By 2026 I predict we’ll see awake techniques become standard practice for single-level decompressions and minimally invasive fusions at major spine centers. Centers that have been doing this work such as the University of Miami, University of California San Francisco have built a strong evidence base. Now it’s about dissemination to more programs.
In the next 12 months specifically, I expect we’ll see increased adoption in the ambulatory surgery center setting. That’s where the real efficiency gains and patient experience improvements become obvious. When you can perform a lumbar decompression on a 70-year-old with multiple comorbidities and have them home the same day, that changes the calculus entirely.
Looking five years out, several trends will converge. First, improved intraoperative imaging and navigation will make minimally invasive approaches even more accessible, and those pair naturally with awake protocols. Second, we’ll see better real-time neuromonitoring techniques specifically designed for awake patients. The ability to check neurologic function intraoperatively is one of the major advantages, and we’ll get better at leveraging it.
Third, patient demand will drive adoption. Just like in joint replacement, where patients now specifically request regional anesthesia instead of general, spine patients will start asking for awake options. The “why would I want intubation if I don’t need it?” question will become standard.
I also predict we’ll see more robust data on long-term outcomes. The early studies show benefits in complications, length of stay, and immediate recovery. But do awake techniques lead to better functional outcomes at one year, two years, five years? That data is coming.
Finally, I think we’ll see expansion to more complex cases like multilevel decompressions, select two-level fusions and procedures we haven’t traditionally considered. As surgeon comfort increases and protocols improve, the envelope will expand appropriately.
Q: Overall, what will be the biggest disruptor to the spine field in 2026?
VY: The honest answer is artificial intelligence, but not in the way most people think.
AI won’t replace spine surgeons. But it will fundamentally change how we approach surgical decision-making. We’re already seeing AI tools that can predict which patients will respond to conservative care versus needing surgery. That’s huge because the best back surgery is no surgery at all. If we can accurately identify the 20% who truly need intervention versus the 80% who don’t, we solve a massive problem.
The disruption comes from transparency and accountability. When AI can show patients objective data about their likelihood of benefit from surgery, it changes the conversation entirely. No more patients undergoing fusion for nonspecific back pain because they found a surgeon willing to operate. No more defensive overtreatment. Just evidence-based decision-making at scale.
We’ll also see AI-driven preoperative planning tools that optimize approach, trajectory, and implant selection. Intraoperative, real-time computer vision will provide feedback on screw placement, decompression adequacy, and technique. Postoperatively, AI will monitor recovery patterns and flag patients who need early intervention.
The second major disruptor will be value-based care models that finally have teeth. As payers shift from fee-for-service to outcomes-based reimbursement, surgeons will be financially incentivized to operate only when necessary and to optimize results. That means more conservative care, better patient selection, and adoption of lower-risk techniques like awake surgery that improve outcomes.
We’ll also see continued growth of ambulatory spine surgery, driven by economics and patient preference. The hospital-based model for routine decompressions and simple fusions is becoming harder to justify when ASCs deliver better patient experience at lower cost.
But if I had to pick one thing that will matter most: it’s the cultural shift toward conservative care as the default. The pendulum has swung too far toward surgical intervention in spine. We’re finally seeing it swing back, driven by evidence, patient advocacy and frankly, the unsustainable economics of overtreating degenerative spine disease. The surgeons who thrive will be the ones who know when not to operate.
