Keeping Patients Awake During Spine Surgery Halves Recovery Time

David B.'s spinal surgery in November wasn't the first—but it was the first time he'd been awake for a procedure.

David, neurosurgeon Praveen Mummaneni, MD, is one of nearly 10 patients who have taken advantage of UC San Francisco's offer of awake spine surgery, which he began doing in the spring of 2018.

“At first I was like, 'Do I really want to be on the lookout for this?' I thought,” he said. But in reality, it was more like being pleasantly oblivious. "I wasn't aware of anything that was going on. It was bedtime."

After the procedure—transforaminal lumbar interbody fusion, or TLIF, which usually only takes two to three hours—David was painlessly up and walking again before the end of the day.

“The procedure is relatively new,” said Mummaneni, co-director of the UCSF Spine Center. “I am changing my practice to be able to do my patients much faster than their surgery.”

Provides Advantage over Local Anesthetic Sleeping

One of the keys to this new approach to spine surgery is a long-acting, local anesthetic called liposomal bupivacaine, which was recently approved by the U.S. Food and Drug Administration. Before the incision is made, anesthetic is injected into the muscle in the lumbar region and provides pain relief for 72 hours.

BENEFITS OF AWAKEN SPINE SURGERY

► Procedures take one to three hours compared to four to six hours for open spine surgeries

► Patients walk on the day of surgery rather than three to four days for standard spine surgery under general anesthesia and usually go home within 24 hours.

► Faster recovery rates mean patients can quickly return to their daily leisure and work activities

► No need for postoperative IV narcotics

► As no general anesthesia is required, patients do not need to be on a ventilator, resulting in a lower risk of side effects and a faster recovery time

"This means we no longer give IV narcotics after surgery," Mummaneni said. "And it allows us to reduce hospital stays by two-thirds."

A traditional spinal fusion surgery with general anesthesia takes about four hours and requires a three to four day hospital stay in addition to IV pain relievers. Awake spine surgery cuts the time in half and typically patients are discharged from the hospital within 24 hours.

Patients may continue to take oral pain medications for a week or two after the effect of the long-acting anesthetic wears off, but overall pain management is much less intense.

The benefits of awake spine surgery go beyond quick recovery times and shorter hospital stays. Patients get over the disorientation and "outside" state caused by anesthesia and post-operative narcotics and return to their lives in a much shorter time. And the absence of general anesthesia means patients do not need a ventilator or breathing tube during surgery, reducing the risk of side effects such as post-operative nausea and delirium.

Low Back Pain Causes Physical and Economic Damage

There is no shortage of people in the US who need back surgery. Diseases of the spine affect Americans more than any other medical condition. About four in five Americans struggle with lower back pain at some point in their lives. According to the National Institutes of Health, about a quarter of them, or 20 percent of Americans, experience chronic low back pain with persistent symptoms.

About four in five Americans struggle with lower back pain at some point in their lives.

According to the National Institutes of Health, the incidence of low back pain has been rising steadily since the 1990s, now the leading cause of missed workdays and the most common cause of work-related disability.

Low back pain often impairs a person's overall health, as it interferes with an individual's ability to exercise and be active. In fact, lower back pain; It now ranks third as a cause of poor health among Americans after heart disease and chronic obstructive pulmonary disease (COPD).

In other words, returning people with spinal disorders to work faster and with fewer complications has economic and social benefits as well as health benefits.

Making Surgery Accessible for More People

Mummaneni's new approach makes low back surgery easier for a wider population of people, for patients avoiding general anesthesia. This group includes most patients who would benefit from traditional spinal fusion or decompression surgery, and many patients who have difficulty tolerating general anesthesia, such as elderly patients.

Awake surgery also appeals to those who are dissuaded from traditional surgery due to its recovery time of one week and longer.

MRI and clinical notes are reviewed to determine if a patient is a good candidate for awake surgery, Mummaneni says. Awake surgery is currently available for one- or two-level lumbar procedures for decompression and/or fusion for the treatment of spinal stenosis and spondylolisthesis. UCSF is one of the first major medical centers in the United States to offer awake spine surgery.

David had suffered from back problems when he contacted Mummaneni last summer. "I've had a lot of surgeries," he said. "I'm not a very novice at this."

Despite previous spine procedures at other hospitals, David suffered from persistent back pain and was referred to Mummaneni by another surgeon. When the UCSF doctor offered him the opportunity to have spine surgery without general anesthesia, David chose it.

“I have zero pain now,” she said. “I spent less time in the hospital, less of an impact on my body, recovery was quicker and I needed less pain relievers.”

https://www.ucsf.edu/news/2019/03/413446/spine-surgery-while-patients-are-awake-speeds-healing