A 91-year-old woman presented with bilateral leg pain that developed after an L5 kyphoplasty for an L5 compression fracture performed at another institution. To accomplish the kyphoplasty at the other institution, the patient was intubated. Her advanced age and a host of pre-existing comorbidities including coronary artery disease, hypertension, congestive heart failure, and pulmonary hypertension led to post-operative challenges after her initial procedure, including an extended intubation time.
Computed tomography (CT) showed that the cement used in the kyphoplasty had moved into the spinal canal, compressing the nerve roots and leading to her intractable leg pain. She tried neuropathic pain medications and steroids, but the leg pain was unrelenting.
While laminectomy could resolve the pain, her original surgeon worried about the strain of another surgery on her body. This led the patient to search for a surgical solution that would be less invasive in every way.
Question: Could Duke Health surgeons surgically address this patient’s pain without exposing her to the risks of another surgery under general anesthesia?
Answer: In close coordination with anesthesiologist W. Michael Bullock, MD, PhD, neurosurgeon Muhammad Abd-El-Barr, MD, PhD, performed a minimally invasive laminectomy under regional anesthesia—called “awake spine surgery.” The procedure alleviated the nerve compression caused by the cement while the patient received carefully calibrated regional anesthesia instead of intubated general sedation.
In addition to reporting only minimal discomfort immediately after surgery, the patient was back on her feet and discharged home less than 24 hours later.
This patient’s age, comorbidities, and previous anesthetic history ruled out a procedure under general anesthesia, which led her to explore the option of undergoing surgery with regional anesthesia instead. While the awake procedure was appropriate for her based on her medical profile, Abd-El-Barr and Bullock believe that awake spine surgery may be beneficial for more people with a variety of medically relevant circumstances.
“This approach to surgery opens the door to more patients who need it, both people who can’t have sedated surgery and even those who can,” says Abd-El-Barr.
Based on data from close to 100 awake spine surgery procedures at Duke Health, the doctors say that most patients who undergo this type of procedure use on average 50% fewer opioids to control pain after surgery. Most also spend significantly less time in the hospital after their procedure.
“By coming together we’re able to minimize the surgical footprint,” Abd-El-Barr adds. “The right candidates for awake spine surgery will do well under regional anesthesia with minimal sedation and have a condition that can be approached minimally invasively to reduce blood loss and tissue trauma.”
“We seek to optimize a patient’s whole perioperative period, beginning with preoperative clinic visits, through surgery, and into recovery,” says Bullock. “To do that takes the full team’s attention -- doctors, nurses and staff from both surgery and anesthesia as well as the patient themselves. The team approach allows us to develop a plan that will help patients recover more quickly by reducing the surgical and medical footprint that may keep them in the hospital longer or lead to detrimental outcomes.”
Bullock also notes that many people are afraid when they hear the term “awake,” but makes it clear that awake can mean different things. At Duke Health, this ranges from truly awake procedures to less intensive sedation options that help “take the edge off” and allow the patient to relax if they have anxiety about staying fully awake.
Duke Health has performed close to 100 awake spine surgeries to date. Today the team performs three to four of these procedures each week. The results for patients such as the one in this case study speak for themselves—she is now one year post operative and continues to be free of bilateral leg pain without the need for narcotics.
For information on how to refer a patient, visit Refer to Duke.