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A kid-friendly (and opioid-sparing) scoliosis surgery · 20-Minute Health Talk

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My approach has always been, how can I make it better?
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And it may be one tiny step, but anything that can make it better.
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That'S Dr. Vishal Sarwahi,
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a pioneer in the field of pediatric scoliosis surgery.
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For me, scoliosis is my passion.
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This is what I live and eat and breathe every day, essentially.
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So I listen to my patients, I talk to them.
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Three years ago,
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I had two kids who came to me with scoliosis who already had history
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of opioid misuse. And around this time, we all know,
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opioid epidemic was becoming a major problem.
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Of course, parents were concerned.
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This presented a dilemma.
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Orthopedic surgeries like scoliosis correction are painful procedures,
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and patients receive large amounts of opioids to help them recover.
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Often, they leave the hospital with 15 days to three weeks of the highly potent,
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highly addictive painkillers. Listening to these concerned parents,
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he knew he had to find another way.
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If you connect with your patient, they teach you.
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You learn a lot from them.
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And what he learned from these two cases inspired
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a major advance in scoliosis surgery,
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one that has led to not only less invasive techniques and faster recovery times,
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but an astonishing 80% decrease in the amount of
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opioids given to kids during and after surgery.
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Hello, and welcome to 20 Minutes Health Talk.
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I'm Sandra Lindsay. For today's episode, we sat down with Dr.
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Sarwahi to learn about his pioneering efforts to reduce
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reliance on opioids in pediatric scoliosis surgery,
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as well as the technical advances he has brought to
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the operating room that are making it possible,
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something he calls the rapid recovery protocol.
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Dr.
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Sarawahi is director of Northwell Health center for Minimally Invasive Scoliosis
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Surgery and the center for Advanced Pediatric Orthopedics at Cohen Children's
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medical centers who are given opioids for surgery are
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at a higher risk of opioid misuse later in life.
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Even more troubling,
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it takes just five days to develop an addiction to this class of drugs,
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which include prescription painkillers like Oxycontin and Vicodin,
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some of the strongest on the planet.
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While dangerous, opioids are a necessary part of surgery,
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particularly major orthopedic operations like those done to
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treat severe scoliosis, which Dr.
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Sarawahi performs daily.
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First and foremost, it is a very safe surgery and a very successful surgery,
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especially in teenage years. So I would put it almost 99% safe, 99% successful.
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What is routinely or what commonly is now being done, we are putting screws.
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You heard it correctly. It's screws, and we put rods in the spine.
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So we're putting screws slightly smaller than my little finger, my pinky finger.
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So two screws at each bone not the whole spine, is fused, obviously.
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We only usually fix the curve, and then we put in a rod, left side rod,
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and right side rod. The rods imagine the screws are like anchors,
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and the rods are the ones which basically straighten the spine out.
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I do a lot of these, so I take about two and a half, 3 hours.
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But on average, people take about five, 6 hours.
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30% of those diagnosed with scoliosis need treatment.
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Just 10% need surgery.
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So, scoliosis is a curve of your spine.
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It's not just a curve.
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It's also a twist. The twisting is very important,
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and it happens mostly in teenage years,
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around the time when they go through puberty and they grow a lot.
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That's when the back starts curving and twisting.
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Unfortunately, it's more frequently in girls.
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And that twist causes another problem.
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And when the whole body twists, the ribs stick out in the back,
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what is called as a rib hump.
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And that's how most pediatricians and patients
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will notice the ribs are malformed or.
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Deformed, something that Dr.
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Sarwahi said is most often caught between ages ten and 15.
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When children hit a growth spurt, it.
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Is obvious you look at the back, you will see it,
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especially if they have tight clothes on or if they're in the swimsuits,
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you will see it. If you look at the back and see something is sticking out,
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or one shoulder blade is sticking out,
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or one shoulder is slightly higher than the other, hips are asymmetric.
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Bring them to the doctor left untreated, any case that would require surgery,
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meaning a curve of more than 40 or 50 degrees will continue to increase
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one or two degrees every year for the rest of your life.
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Dr. Sarawahi explained, if I'm 20.
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Years of age and I have a 50 degree curve, in 20 years,
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that curve can be anywhere from 70 to 90 degrees.
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Now, that's a big curve.
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Can we fix it at that age?
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Sure enough, we can. But at 20 years of age, it is 99% safe,
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99% successful surgery. Same surgery at 40 years of age is only 70% successful.
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Not just that, it's a big curve.
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So you will get less correction.
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Not just that,
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that curve is big enough that it's going to push on your lungs
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and compromise the lungs. So your breathing goes down a bit,
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your lung functions get compromised,
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and the fear is that it will start affecting your heart,
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it usually will not kill you,
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but it will definitely compromise the quality of your life.
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There are some studies actually coming out of Italy, an untreated scoliosis,
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where there is about 20% mortality because of heart and lung problems
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later on at that age.
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So obviously, you don't want to be there.
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The best thing is to get it fixed.
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Correcting this rib hump, Dr.
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Sarwa, he told us,
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could require shaving down the rib or even breaking and removing
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one or several to return the body to a normal shape.
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And that hurts. Crack ribs hurt.
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With such a major surgery, controlling pain is critical to a patient's recovery.
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Opioids are crucial, especially for bad pain, not your routine ankle sprain.
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This is surgical pain. This is painful.
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If I'm cracking your ribs, if I'm cutting your bone, it is painful.
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I won't lie to you.
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That's the first thing that these teenagers are concerned about, is pain.
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Essentially, pain delays recovery.
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Pain can become chronic if you don't treat it properly.
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So for the rest of the life, they'll be experiencing pain.
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But opioids, given at the right dose for the right duration,
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can manage it safely. Problem is, as we all know, they are addictive.
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Opioid addiction affects all ages and communities and has contributed to drug
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overdoses becoming one of the leading causes of unintentional death in the US.
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Tragically, the risk to kids is only getting worse.
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The CDC reported a 94% spike in overdose deaths among kids 14 to 18 years
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old from 2019 to 2020.
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That number increased 20% from 2020 to 2021.
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About 90% of those deaths involved opioids,
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according to the CDC's state unintentional drug overdose reporting system.
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A major factor driving this trend has been the widespread availability
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of fentanyl, which is 50 to 100 times stronger than heroin.
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United States has lost more people to the opioid epidemic.
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And this is not just prescription combined everything fentanyl and everything
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illegal and everything, than in the entire World War II.
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I mean, to me, that is a gut wrenching fact.
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This problem started. Dr. Sarwa, he said,
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when the idea became getting pain down to zero, pain.
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Was considered the most important thing in terms of recovery.
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Not just surgery, anything. Sprain even getting a wisdom tooth removed,
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essentially.
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so trying to avoid pain became, at that time, the most important directive,
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not just from patients or parents, but also from the government or the CDC.
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Everybody was talking. FDA was talking about pain, managing pain, managing pain.
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And I think we ran away with it for quite some time,
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and with the right intention.
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Unfortunately, this problem continues today.
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In general, the standard all over the country is lots of opioids.
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They do give this thing called the PCA, which is patient controlled analgesia,
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so that we attach you to an IV line with a pump which
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keeps pumping a basal rate, a fixed, constant rate,
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every hour for two days in the hospital for five to seven days on an average,
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and they would go home with 15 to days to three weeks of oxy and other opioids.
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The problem with all that is when you get too much of morphine, a,
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the pain never goes down to zero.
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But then once we started realizing that there are problems and
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people are getting very addicted very quickly and very early
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people start asking questions,
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are we overdoing this? And slowly, the change happened.
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Around this time, two patients came to Dr.
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Sarwahi in need of scoliosis treatment.
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In each case, surgery would be called for, but there was a problem.
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Both had a history of opioid misuse,
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which the parents let him know faring what might happen if their
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child was given large amounts of opioids for surgery.
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When these kids came to me there was a comeback of duramorphic medicine.
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Duramorph is a type of opioid given as an injection
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in the spine to control severe pain.
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For context,
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it is ten times more potent than an epidural and has been routinely used
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in much smaller doses, called microdoses, during C section deliveries.
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Reading about its use in other types of surgery, Dr.
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Sarawahi wondered if these two patients, and more broadly,
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all scoliosis surgery patients, could benefit.
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Now, the beauty of Duramorph is that it's hydrophilic.
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It loves water, essentially,
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so it gets attracted towards anything that is watery.
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And CSF, that is a spinal fluid that we have is watery.
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So it gets dispersed along the whole spine, top to bottom, essentially,
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because the.
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Medication remains within the cerebrospinal fluid for several hours,
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patients wouldn't need as high a dose to control pain from surgery.
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In 2018, Dr.
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Sarawahi presented the idea to his pain management team at Cohen Children's
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Medical center, including the hospital's chief of anesthesia, Dr.
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Michelle Cars.
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A lot of conversations. We put a team together, along with Dr.
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Carrs and the other pain management team of our physical therapists,
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social workers, nurses, that this is what we're going to do.
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and we said, this is a trial thing.
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Dr. Sarwahi decided to begin a trial using duromorph.
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He kept patient controlled anesthesia on standby,
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but felt that the patients wouldn't need it.
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There was just one unknown.
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The question came down to the dose.
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What would be the right dose?
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Obviously the higher dose puts you at high risk of respiratory depression.
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So we did not want to go to a higher dose.
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In the pediatric surgery, they had tried two to four micrograms.
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We wanted to bring it down.
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Dr. Sarwahi landed on 1.5 micrograms for his two patients.
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For scale, 1 μg is equal to one 1000 of a milligram.
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So for a 90 pound child, that would be 61 micrograms.
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By comparison,
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patients on PCA received 25 to 50 milligrams of morphine IV per day.
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Started with two cases. They did well, then we started with ten,
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then we reviewed it, then went to 50.
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We reviewed, and then pretty soon, it became standard.
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So we slowly started putting that as a protocol.
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But initially, there was resistance as it.
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With anything new. I'm like, no,
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it is a dose which is given at the right place
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because it primes your nervous system.
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and since then, we have never looked back, and we have done,
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I have now 500 kids who have been treated this way.
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This approach was the first step in what Dr.
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Sarawahi calls the rapid recovery protocol.
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So, rapid recovery protocol started elsewhere.
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Other places started doing it maybe a year before we came up with this.
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We were initially hesitant because they still use PCA for about a day
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and a half. And to me, that was still 50 milligrams extra morphine.
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So we were hesitant in doing that.
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So we put together our own rapid recovery protocol, which is basically,
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they go home in three days.
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So an hour after the surgery, they can start eating,
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which is not true for the PCA because they are nauseous.
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They cannot eat for almost a day or two.
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My kids can start eating an hour later.
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That means they can swallow pills,
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so I don't have to give them injectable morphine.
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And we depend a lot on tylenol and edible alongside.
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Of course, we do have, for three to five days, some oxycodone.
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but mostly not much of injectable.
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Compared to patients receiving PCA,
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those benefiting from the rapid recovery protocol received nearly one 10th of
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the amount of morphine and were prescribed half the amount
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of oxycodone post surgery, according to a 2021 paper Dr.
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Sarwahi published in the journal spine.
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one night in the ICU, second day, they're sitting up.
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Third day, they're climbing stairs.
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Usually they go home in three days.
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And when I send them home.
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I send them home on three to five days of some oral pain medications.
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The microdose does require surgeons to not only think differently about pain
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management, but to thoroughly prepare their patients on what to expect.
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I always educate my patients.
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I tell them, hey,
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expect the pain to be around three to four on a scale of zero to ten.
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a lot of time when you prepare them.
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kids are smart, they understand,
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they listen and their expectations are accordingly fine tuned.
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Essentially, we almost decrease the opioid consumption by 80%,
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and I'm very proud of it.
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It's a big, big thing.
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80% less opioids and better pain control.
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The journey still continues. So this is not the end of the duramorph.
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We are now looking at if there is a difference, and actually, there is.
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If the duramorph is given before surgery by the anesthesiologist,
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before they go under anesthesia, or before even I make an incision,
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versus if I give it at the end of the surgery,
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that three hour difference makes a huge difference in the amount of opioids.
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So if they get injection before the surgery,
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the nervous system is already primed, so they wake up much better,
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requiring less pain medication.
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Since publishing these findings in 2021,
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he and his team continue to update this technique
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and explore new ways to improve the surgery.
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Technology has evolved. Our technique has evolved.
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So in a classic scoliosis surgery, we open your back,
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you move your muscles away, and we have to expose the entire bone, essentially,
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and then we reattach it.
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But moving muscles,
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if anybody who has had a sprain of the ankle or the knee and a
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major sprain will attest to that, it's a very painful thing.
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Now, imagine your whole back has been sprained.
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but the same surgery, I have been doing it in a less invasive manner.
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I don't strip your muscle the same way, so essentially,
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I'm preserving your muscles.
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So I find the natural plane that exists between those muscles.
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So imagine if I keep my fingers next to each other and I'm just separating
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those fingers out instead of chopping those fingers away.
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So I just separate those.
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Your muscles are still attached.
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I find the natural plane that exists, and through that plane, I put my screws.
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So obviously, less painful, less blood loss and faster recovery.
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In fact, the study that we published a few years ago, we found, like,
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almost 90 9% of them did not need a blood transfusion,
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which is compared to if 20% to 30% patients require blood transfusion,
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is a major win. The downside is it does take a little bit longer,
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but with experience, this should decrease.
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Also,
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this minimally invasive approach started taking shape ten years
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ago and also takes into account the scars left by surgery.
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So scoliosis, it depends on the type of the curve.
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Sometimes you have two curves.
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Sometimes it can be your whole back.
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But instead of now one long incision back,
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I'm getting away with three non contiguous,
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so they're not connecting to each other.
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incisions. so if you have a swimsuit on,
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probably you will not notice a long incision.
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You just might notice a tinier incision.
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But it's not about the incision, right.
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It is more about pain and long term benefits of it.
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So we realized, know, this approach has been in place for quite some time,
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and we just combined two plus two together, and we came to this.
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The latest evolution to. Dr.
18:41
Sarwahi's approach aims to improve accuracy when placing screws during scoliosis
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surgery. And he's doing it using a combination of technique and technology,
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or TNT for short.
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Now, I've put almost 70,000 screws now.
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and you always worry that what is happening if, by chance,
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the screws are misplaced?
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And with good reason. In typical scoliosis surgeries,
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screws are misplaced around 30% of the time.
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But when Dr. Sarwahi checked his work.
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My accuracy rate confirmed on cat scan is about 93%.
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Luckily, most of the screws are lying next to the muscles or ligaments,
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and they're not endangered. But you have to understand what the risks are.
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so I told you, we put screws into the spine,
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and the screws actually go from the back of the spine through
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the middle of the spine to the front of the spine.
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The problem is that when we're putting the screws in,
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we are not seeing the front of the spine or the middle of the spine.
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We just see the back of the spine.
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One wrong move, he says, and surgeons could damage the spinal cord,
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lead into paralysis, or even vital organs like the heart and lungs,
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which could be deadly.
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So you have to do this either under x ray vision, which is fluoroscopy,
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lots of radiation or just by field.
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so technology has been evolving to try to help surgeons
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put screws in a much more safer manner.
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We have navigation technology that has been around for at least ten years or so,
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where people are doing CAT scans before the surgery.
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And based on that, then you use navigation during the surgery.
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So think of it like navigation, your car navigation, right?
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I mean, you go home every day you drive, every day.
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You know the roads,
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but still you switch on your Google Maps because it
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may tell you the faster way of reaching there.
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The problem with that, he told us,
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was you still didn't know if your screws were placed accurately
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because scans were taken before placing the screws, not after.
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You'Re presuming that your screws have been placed accurately.
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He acquired an intraoperative CT scan machine called Arrow and began taking
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scans during and after to confirm the placement of screws were accurate.
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But he found another downside.
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When we started adapting this technology
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my two and a half, three hour surgery became a four or five hour surgery.
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And you may say, well, it doesn't matter, but it does matter,
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because longer surgery means more anesthesia for the patient
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more chance of blood loss, more chance of infection.
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why would I want. And more pain.
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Why would I want that?
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So we came up with this thing called TNT,
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which is a short form for technique and technology.
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I have the surgical technique of putting screws.
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I've been doing it all these years.
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I'm pretty facile with it, so I can put those screws.
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As I start putting screws,
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there will be one or two areas which will be challenging.
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I can skip those, and I continue putting the remainder of screws.
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And once I'm done, I bring in my CaT scan.
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It takes two minutes for the CaT scan to spin.
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I see all my previously placed screws.
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I adjust them if I need to.
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And those one or two that I've skipped, I can now use navigation,
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and pretty soon,
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I've been able to put it back to two and a half hours and with
22:09
better accuracy now. So that approach we call as TNT,
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it is as if we are combining all these things together and not only
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making surgery safer, but also more efficient and outcomes better.
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Dr. Sarwahi is now studying the effectiveness of his TNT approach.
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We are the only place in the country which is doing it.
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This technique gives me best of both worlds.
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As we wrapped up our conversation, Dr.
22:37
Sarawahi said parents and patients are thrilled to
22:41
hear that opioids are not so heavily relied on.
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Parents are asking for it.
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kids have become smarter.
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They are on board with this, but parents are demanding it equally.
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While many continue to use PCA and prescribe opioids for surgical pain,
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he said he sees a positive trend of surgeons looking for ways
23:04
to reduce their reliance on the dangerous painkillers.
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Be a skeptic, not a naysayer.
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You should be a healthy skeptic, not everything is absolutely correct.
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and absolutely right. In medicine, sometimes things become a fad.
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but if there is enough evidence, parse the evidence, look for it,
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and talk to the guys who have done it, and they'll tell you,
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because there are nuances to this.
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not everything
23:32
is as successfully reproducible everywhere.
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So, for example,
23:36
a TNT approach
23:39
not everybody will be able to do it,
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because you have to have that experience of putting screws
23:44
in that way kind of thing.
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If you're not, I will say,
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stick with the navigation because you don't want to harm first, do no harm.
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Right. But for the duramorph, the opioid thing, that is not that difficult.
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if you are hesitant doing it, ask your anesthesiologist.
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They'll be able to help you.
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People are willing to help.
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You have to seek collaboration.
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Education is constant.
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What you have learned ten years ago probably is not going to be accurate today.
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It has to change. We have to change.
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Reflecting on the many advances he has made to
24:16
scoliosis surgery in the last decade, Dr.
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Sarawahi thought back to those two patients who
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started him down this path ten years ago.
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Had it not been for those two patients,
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I would still probably be practicing what others are doing.
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So
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my approach is, I listen to my kids.
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That does it for this episode.
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Thank you to our guest, Dr.
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Vishal Sarwahi,
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for sharing his inspirational story on behalf of our podcast team.
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Thank you for listening. Until next time, I'm Sandra Lindsay,
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and this has been another episode of 20 minutes health Talk.