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Awake Spinal Fusion

Is awake spine fusion a viable treatment choice in this 48-year-old male?

History

The patient is a 48-year-old gentleman who developed a lumbar disc herniation at L5-S1 in 2017. At that time, he tried various nonsurgical treatments including nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy and epidural steroid injections (ESIs). Despite these interventions, his low back pain and right leg pain persisted. Subsequently, he underwent L5-S1 microdiscectomy and laminectomy with great success.

Two years after lumbar spine surgery, his symptoms have returned, including low back pain and right leg pain.

Examination

The patient complained of equal low back and right leg pain. His physical exam was normal except for slight numbness in his outer toes.

Prior Treatment

Again, the patient tried a course of organized physical therapy and ESIs without meaningful relief.

Pretreatment Images

Preoperative sagittal lumbar MRI; disc reherniation at L5-S1Figure 1. Preoperative lumbar MRI. Image provided by Alok D. Sharan, MD and SpineUniverse.com.

Preoperative sagittal lumber MRI, L5-S1Figure 2. Preoperative lumbar MRI. Image provided by Alok D. Sharan, MD and SpineUniverse.com.

preoperative axial lumbar MRIFigure 3. Preoperative axial lumbar MRI. Image provided by Alok D. Sharan, MD and SpineUniverse.com.

Diagnosis

A new MRI series revealed an L5-S1 reherniation with complete disc space collapse and Modic type 1 endplate changes.

Suggest Treatment

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Selected Treatment

Two “awake” surgical treatment options were presented to the patient; either a L5-S1 revision laminectomy or transforaminal lumbar interbody fusion (TLIF). The risks and benefits of each approach were discussed.

The patient decided to proceed with the Awake Spinal Fusion procedure (Awake TLIF at L5-S1).

Surgeon's Treatment Rational

Awake spinal fusion has become our preferred treatment choice for patients who need to undergo 1-level spinal fusion. It is critical that the surgeon has fairly predictable OR times to complete the procedure. Our surgical team, including the assistant, anesthesiologist, scrub tech, x-ray tech, and circulating nurse are fairly consistent, which helps with predictable OR times. We dose our spinal anesthesia to give us 1-1.5 hours of OR time.

The combination of fentanyl in the spinal anesthesia along with liposomal bupivacaine (Exparel) in the TLIP block gives us tremendous pain control after surgery. Since these patients do not experience nausea and vomiting post op we are able to ambulate them much quicker—often discharging them quicker.

It is very rare that we do not perform our TLIF’s “awake”. We originally thought patients with respiratory co-morbidities would be an exclusion criterion. We often find that performing their surgeries under spinal anesthesia are easier as they are able to manage their breathing issues better.

During surgery, we try to give minimal sedation so that patients do not become disinhibited. This prevents any sudden movements while performing surgery.

Awake TLIF Procedure

Awake spinal fusion is a relatively new technique that encompasses a combination of spinal anesthesia with a regional block. Spinal anesthesia has a long history in spine surgery. Just recently there have been new publications describing various regional blocks for spine surgery. In this patient’s surgery, a thoracolumbar interfascial plane block (TLIP) with long-acting Exparel was used in the TLIP block.

The awake TLIF was performed minimally invasively using a bilateral Wiltse approach. The facet joint was removed allowing for adequate decompression during the TLIF and cage placement. Percutaneous pedicle screws were implanted using standard C-arm image guidance.

Postoperative Images

postoperative lumbar lateral x-ray, TLIF at L5-S1Figure 4. Postoperative lateral lumbar x-ray. Image provided by Alok D. Sharan, MD and SpineUniverse.com.

postoperative PA lumbar x-ray, TLIFFigure 5. Postoperative posteroanterior lumbar x-ray. Image provided by Alok D. Sharan, MD and SpineUniverse.com.

Outcome

A few hours after surgery, the patient was able to ambulate and go home the same day.

We have developed a protocol whereby we are trying to get patients to ambulate, receive one dose of antibiotics, and an x-ray within 4 hours after arrival into the recovery room. While we have not achieved 100% success yet, our goal is to work towards making Awake Spinal Fusion an ambulatory procedure. Achieving this of course requires a lot of “parts” in the system to work together. For example, if we give too much spinal anesthesia it may take longer for the medicine to wear off—potentially delaying discharge.

The patients are given a prescription for narcotics and muscle relaxants after surgery. For the patients who are narcotic naive before surgery, we find they usually do not require another narcotic script post op. In this case, the patient did not need opioids 1 week after surgery. He was able to return to his desk job 2 weeks after surgery.

Surgeon's Discussion

We have been performing the Awake Spinal Fusion procedure for over two years now in more than 90 cases. The average length of stay is 0.8 days in the non-worker’s compensation population. At this point >40% of patients who undergo awake spinal fusion go home the same day.

There are many downstream benefits to avoiding general anesthesia when performing spinal fusion surgery. There is tremendous evidence that general anesthesia in the elderly population can lead to delirium. In addition, avoiding general anesthesia and using light sedation enhances the recovery as many patients do not experience nausea/vomiting after spine surgery.

At a time when surgeons are looking to perform these cases in a more efficient manner, and perhaps move these cases to outpatient settings—awake spinal fusion surgery offers a reasonable alternative method to achieve the same outcomes at a lower cost.1

Reference
1. Sekerak R, Morris M, Sharan AD. Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery. American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting, March 12-16, 2019, Las Vegas, NV. Paper 750 presented March 15, 2019.

Peer Discussion

This is a 48-year-old male who had history of L5/S1 recurrent herniated disc following a prior microdiscectomy in 2017. He has failed conservative care and reports back pain and radiculopathy.

In patients with recurrent disc herniation, with MRI showing degenerative disc disease, and with clinical correlation with back and leg pain, a fusion is a viable option supported by the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) lumbar guidelines.

One surgical option for this patient would include anterior lumbar interbody fusion (ALIF) with a subsequent posterior open decompression and pedicle screw fixation. The advantage of ALIF is that it allows for a large graft and has a high fusion rate. The disadvantage is that two separate incisions are required and there is the chance for ileus.

Another option is a transforaminal lumbar interbody fusion (TLIF) , either minimally invasive surgery (MIS) or open. This patient has a unilateral stenosis that is amenable to MIS TLIF. We typically reserve open TLIF for patients who have severe bilateral canal stenosis and prefer MIS TLIF for patients with unilateral stenosis in our practice.

Furthermore, by removing the facet joint, the surgeon can steer clear of the scar tissue from the prior discectomy and find a virgin epidural plane to remove the recurrent herniation and avoid a CSF leak. Recently, like Dr. Sharan, we have employed a spinal anesthetic to do these cases “awake”. No general anesthesia is used, and the patient has analgesia with a spinal block and local injection of liposomal bupivacaine in the Wiltse plane. This strategy has worked well in our practice to avoid the side effects of general anesthesia (nausea, delirium, temporary memory deficits).1

The caveats of doing a TLIF “awake” is that the operation needs to be done expeditiously before the spinal anesthetic wears off and the patient becomes uncomfortable. In addition, patients who are obese with sleep apnea are not good candidates for awake TLIF as they have difficulty with their airway when prone. Finally, an experienced anesthesia team is very helpful in completing an “awake” TLIF.1

We congratulate Dr. Sharan on an excellent radiographic result for the patient. The patient needs to be followed for 1-2 years to ensure the bone graft heals (and if it does not, we would then proceed with a salvage ALIF).

Reference
1. Kai-Hong Chan A, Choy W, Miller CA, Robinson LC, Mummaneni PV: A novel technique for awake, minimally invasive transforaminal lumbar interbody fusion: technical note. Neurosurg Focus 46 (4):E16, 2019.

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