Alok Sharan, MD, co-director of the Westmed Spine Center in Yonkers, N.Y., began performing awake spinal fusions in 2017, and has just reached a milestone: 100 successful awake spinal fusions performed.
During the minimally invasive transforaminal lumbar interbody fusion procedure, patients are put under both spinal and regional anesthetic. They often wear headphones during the procedure and listen to music, which improves their overall experience. Over time, Dr. Sharan built a protocol that prepares patients for surgery to return home within 24 hours of the procedure. The 100th patient was a 63-year-old who returned home the same day.
"As a doctor, it's a tremendous accomplishment to perform 100 awake spinal fusions because we took one operation, spinal fusion surgery, and transformed the experience," said Dr. Sharan. "My conclusion is that awake spinal fusion is the next iterative advantage in minimally invasive spine surgery. It's an enhanced recovery protocol that in my mind, when you do it, leads to less pain, faster mobilization and an overall quicker recovery."
So far in 2019, around half of Dr. Sharan's patients are discharged home the same day, with an average length of stay of 0.8 days. The procedure has also been effective in lowering narcotic use postoperatively; around 60 percent to 70 percent of the patients don't require narcotics a week after surgery. These results show awake spinal fusion could be an ideal procedure to achieve the goals of value-based care. Commercial and government payers are now challenging healthcare providers to improve quality and lower costs for the 90-day episode of care, not just the surgical procedure. Value-based care also takes the patient experience into account.
"You can’t make spinal fusion surgery a better experience by thinking about just what happens in the operating room," said Dr. Sharan. "It's about educating the patient properly, doing a proper risk assessment of the patients to understand how to optimize them before surgery, and making sure they understand all aspects of the procedure prior to surgery. You want them to engage with your nurses at the hospital and buy-in to following your protocol."
Consistent messaging across all nurses and staff members will help patients set the right expectations for surgery. When surgeons intend for an outpatient procedure, everyone involved should continue to reiterate the plan to ensure the patients return home the same day. The surgeons should also be prepared to increase touchpoints with patients after they return home so they don't feel abandoned during the process.
Dr. Sharan isn't the only surgeon performing awake spinal fusions; a few others around the country have adopted the technique as well. "My goal is to personally understand how to optimize the patients better and refine the criteria for patients who are good candidates for outpatient fusions," said Dr. Sharan. "At some point, we'll partner with a company or organization that can help us gather good scientifically balanced evidence around this, which will lead to cost-effectiveness. Then we will need to create an alternative payment model that incentivizes surgeons to perform procedures using our awake spine surgery protocols. Increasingly there will be a greater need for spinal fusions in the future, and if we can find a more cost-effective way of performing them, we can get payers on board."