While You Weren’t Sleeping: How 3D Imaging Tech Is Enabling ‘Awake Spinal Surgery’

Dr. Ernest Braxton* is used to performing surgery in challenging situations. He spent 10 years in the military, including a deployment as a theater neurosurgeon in Afghanistan, where he worked with soldiers who suffered traumatic brain injuries and complex spinal fractures. After his transition to civilian life in 2017, he made the decision to help patients in new ways in Vail, Colorado.

After extensive experience in extreme circumstances, it’s perhaps no surprise that Dr. Braxton is open to trying new things in his own neurosurgery and spine care practice. While neck and back pain are common ailments for many, the resulting discomfort can have life-altering disabilities. Dr. Braxton’s chief concern is helping his patients improve their day-to-day quality of life — but that’s something that can seem almost impossible in the face of debilitating neck and back pain. To help get them back to a more active lifestyle, Dr. Braxton’s passion for patient care has led him to be an early adopter of new technologies and techniques in spinal surgery — including minimally invasive procedures like “awake spine surgery.”

Awake spine surgery is a relatively new and emerging minimally invasive technique. “We’re still really in our infancy,” Braxton says. “There are not a lot of surgeons doing it this way.” The doctor uses awake spine surgery for lumbar microdiskectomy, lumbar laminectomy, and minimally invasive fusion — all operations that treat back and leg pain. As the name implies, patients are awake during surgery and do not undergo general anesthesia. Instead of fully sedating patients, Braxton numbs the surgical site with local anesthesia to prevent them from feeling pain or discomfort during the procedure, and the surgical team provides care to ensure their comfort throughout the procedure.

 

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During these surgeries, the patients can chat with Braxton — “Sometimes I feel like a hairdresser,” he jokes, “like, ‘Tell me what’s going on with your son’ or ‘What’s new with you?’” — or they listen to music on headphones. Braxton has been experimenting with letting patients watch videos on an iPad, but only if the videos are soothing. “No sporting events or comedies,” he clarifies. That’s because sports fans get very emotional, and emotion makes them move around. The one time he allowed a patient to watch a game, he says, “it was like a roller coaster ride.” Someday he hopes to introduce virtual reality headsets as another way to help patients relax in a calm setting during the procedure.

There have also been other benefits to the operating room environment when a patient is awake. “I think that the operating room ends up being a bit more respectful, a little bit more efficient,” he says. “It’s a patient-centered room.” A patient who’s awake can tell Braxton if they’re uncomfortable or in pain, and the surgical team is able to make adjustments — which helps give the patient a sense of control over what’s happening to them. It also makes the team more aware that they’re operating on an actual human being. That, in Braxton’s opinion, is better medicine.

 

“I think that the operating room ends up being a bit more respectful, a little bit more efficient,” he says. “It’s a patient-centered room.” 

 

As a surgeon, Braxton is also much more aware of time with an awake and conscious patient. The surgery needs to be completed before the local anesthetic wears off, which gives him a window of about two hours. Focusing, of course, helps him work more efficiently, but he’s also gotten a boost from technology, specifically the GE HealthCare OEC 3D imaging system.

 

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One of the technology’s innovative features is a camera in the OEC 3D detector that gives doctors a real-time view of the surgical site, which can help minimize X-ray shots and setup time. The OEC 3D also brings efficiency, with the ability to take 2D X-ray (like a picture) as well as 3D volume imaging (like a CT) in a single, all-in-one system for use during time-sensitive procedures. By using the OEC 3D, Braxton can get precise images that can be reviewed in minutes right in the procedure room, with no need to schedule and wait for additional post-op imaging. “Once you have 3D imaging, it’s really hard to go back to 2D,” says Braxton. “It’s like having a mobile phone and then going back to a rotary dial phone.”

The OEC 3D also provides a larger 3D volume than imaging systems Braxton has used before. This allows him to see more levels of the spine without necessarily having to make more incisions. On a practical level, the large 2D and 3D field of view also means he doesn’t have to spend as much time centering the X-ray image or doing additional imaging — which can help reduce the overall amount of radiation. The technology also memorizes the motorized positions, so Braxton and his team can look at the surgical area from different angles without guessing the previous positions. With this efficient imaging system, Braxton says, he can take more 3D images, more frequently, during surgery to get a more complete anatomical picture.

Recently, Braxton says, he was doing a surgery with very small incisions. In the traditional 2D view, the final result looked as planned. “Now, with the ability to get a 3D spin,” he continues, “I saw a slight medial breach of the screw — I mean, it was millimeters. But if football is a game of inches, neurosurgery — and, in this case, screw placement — is a game of millimeters.” The OEC 3D image enabled Braxton to reposition the screw so it was in the right spot.

 

"But if football is a game of inches, neurosurgery — and, in this case, screw placement — is a game of millimeters.”

 

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Immediately after surgery, Braxton has seen this minimally invasive approach help improve post-op recovery at his outpatient clinic — from allowing patients to get up and move more quickly to minimizing postsurgical disorientation as well as pain and nausea from the anesthetic.

Together, he believes all these different elements help create a better environment for the patient.

As he looks to the future, Braxton plans to continue performing awake spine surgery at his outpatient clinic and is always seeking new opportunities to learn and improve how he provides care to his patients.

“I’m not just performing a function,” he says. “It’s led to a lot more interest in what is causing pain. And I’m just a little bit more gentle when I operate. I’m telling myself, ‘I gotta help this lady. She’s got responsibilities. She’s got expectations. I can’t let her down.’”

It’s this bond, he thinks, that has made him a better doctor.

 

* Paid consultant: Dr. Ernest Braxton is a paid consultant for GEHC and was compensated for participation in this interview. The statements by Dr. Braxton described here are based on his own opinions and on results that were achieved in his unique setting. Since there is no “typical” hospital, and many variables exist — e.g., hospital size, case mix, etc. — there can be no guarantee that other customers will achieve the same results.