Mayo Clinic can perform lumbar fusion, as well as laminectomy and diskectomy, with spinal anesthesia. The awake procedures can lessen operating room time and postoperative pain.
Dr. Abode-Iyamah, a neurosurgeon at Mayo Clinic and Dr. Bojaxhi, an anesthesiologist will discuss this procedure and the benefits they are seeing with patients, the types of patients that would be a good fit for this surgery, the importance of collaboration between the anesthesiology and neurosurgery teams and more. I'm pleased to introduce today's speakers for the webinar. Please join me. Please join me in welcoming Doctor Kingsley Abode Yama, a neurosurgeon from Mayo Clinic in Jacksonville, Florida. He is passionate about and specializing in complex spinal deformities. And his research interests include innovations in the spine, cervical myelopathy, spinal cord injury, spinal cord tumors, finite element modeling and biomechanics of the spine. He is currently engaged in numerous clinical projects including uh retrospective studies and prospective studies along with Doctor Ibo Yama. We have Doctor Aler Boi who is assistant professor of anesthesia and pert of medicine at Mayo Clinic in Jacksonville, Florida. He has a dedicated focus on neurosurgical anesthesia and acute pain management at Mayo Clinic, Florida. Doctor Bag holds a position of chair of the Sedation committee and chair of the Neuro Anesthesiology. He is actively contributes to the advancement of the medical practices and leads the development of the awake craniotomy and awake spine program in collaboration with the esteemed neurosurgical team. Doctor Boyi expertise extends to various domains including regional anesthetic techniques for neurosurgical patients. Same day, spine surgery, and effective management of acute and chronic pains. Following major spine surgery. His passion for the enhancement of patient outcomes in the realm of neuro anesthesiology drives his commitment, deliver exceptional care. Welcome to you both. Thank you very much. Thank you for having us. All right. So we're gonna start off, we have a, a quick video for you everyone to watch and then we will go from there. OK? Next, how you doing? So all we're just closing off the skin light right now. OK? You did very, very well. All right. All right. Thank you. I'm gonna put this back in the sun was last and you're gonna roll right over it. Ok? And I'll just bring the face pillow to help you. Ok? 123. And he's done pretty. Ok. Well, thank you for, um, uh, watching that video as you can see, um, awake spine surgery even using the robot is, uh, very possible, but it's not always, uh, available for all patients. There are some patient selection criteria that we use for these, um, for these procedures. One is the, uh, patient's preference, which is, I think is probably the biggest factor. Um, a patient has to be willing and wanting to have an awake spine surgery, uh, for, for us to select that patient. Another one is that we try to keep, uh, A BM I of patients to less than, uh, 35 patient with severe, um, obstructive sleep apnea. Um, those with, uh, nexo professors around above 40 stop bank score up greater than five not good candidates for this. And this is something that our preoperative team typically measures on all of our patients. Uh Patients with claustrophobia are also not great patient sele uh not great selected patients for these. And then uh uh patients position, uh patients that are unable to uh lay prone for the length of time of the procedure or those that have shorter Imo uh immortality, immobility that would uh cause them pain. Now, we try to limit these procedures to ones that would be 100 to 100 100 and 20 to 100 and 80 minutes, which is typically the time that that spinal uh block would last. So the type of surgeries that we would choose for this uh are simple laminectomies. And uh this can be one of multiple levels. Um uh laminectomy and vasectomy patients with a herniated disc, um would also be good candidates for this uh minimally invasive fusions. And so, 1 to 2 level fusions are also patients that can undergo these procedures in, in this time frame. All right. Thank you very much. Uh Doctor Borea. Um That, as you mentioned, the screening of the patients uh is, is critical and then occurs in the neurosurgical office. And uh that also is gonna occur in our preoperative clinic and that's key to our success and, and also educating the patient about how to anticipate the day of surgery. Uh One of our goals for these cases are to really come up with uh AAA formula that just goes beyond by just getting that spinal for the for the case. We also want to set these patients up for success because that's we know that that spinal is gonna wear off. And that involves having good uh multimodal analgesics on board and also taking extra precautions uh in terms of uh nausea and vomiting, prophylaxis because really our goal is at the end is that once that spinal wears off, we really wanna make sure that these patients are, are ready to mobilize and and assess how they feel. And, and then we can address any concerns that they have. Uh So for multimodal analgesia, it, it starts preoperatively. We gave the patients, we start them off uh with uh uh some acetaminophen, we'll give them some CeleBREX and an anti inflammatory. And we also frequently use uh a prepotent uh orally uh for po nausea and vomiting uh in the operating room, the patient will receive some steroids, uh some dexamethasone. Um And then uh we'll give some Aden famotidine if needed. And uh we usually finish with uh uh methocarbamol to help with any back spasm and the patient then in the post-operative period, we try to bypass them, needing any intravenous uh analgesics. So we try to set them up on a uh regimen that will also be appropriate for them to be discharged with. Uh So that would be including uh oral uh analgesic medication A as shown here. So again, it's acetaminophen, methocarbamol and uh oxyCODONE. The other technique that we utilize to help the patient with post-operative pain is uh preoperatively. We perform uh an erect spinal pain block uh here in the holding area. Uh The reason we performed this block is again, is is we're gonna anticipate that spinal wearing often in the recovery area. So we want them to have some level of analgesia uh as the spinal wears off. Um The reason we perform this block in the holding area is that we also wanna assess uh how the patient is doing. Uh Occasionally this block has been associated with uh leaking a little bit in the fair vertebra's space and numbing up a little nerve roots. Uh So you want to know that, you know, if there's a little numbness or so forth, was that due to the block? You don't wanna find that out at the end of surgery. This obviously is very rare. Uh as shown here on the ultrasound guidance. Uh We usually inject the uh bibic about uh 10 to 15 and it's a combination with uh Lepiz Pine in this example, uh where 10 to 15 CCS of locals injected on each side. Then once we arrive in the operating room, this is where the spinal anesthetic uh is performed. Uh We keep a very light level of sedation. This would have been started in the holding area. As you mentioned, that's what we're doing. The e electrospin plane block and the patients are fairly calm once they arrive in the operating room, uh, we perform the spinal, we usually use uh bupivac preservative free half percent and then sedation is resumed using uh Dexin Aamo. Uh We try to keep our doses fairly light. We want the patient to be able to respond to our questions and them to address any to, for them to be able to bring any concerns to us. Uh supplements if the patient needs a little bit more lysis, uh might be given a little bit of midazolam or uh a very light dose of propofol uh during the procedure. The next step and this is a critical step uh is positioning the patient and is position the patient to comfort. Uh And it's also important here that the patient is not too sedate it. So that's uh so the careful titrations of those sedatives uh in the earlier period is is critical. Uh the patient is assisted to go in the prone position and they're placed in a, a foam pillow. As you see here. Uh At this stage, we make, we want the patient to communicate with us is their neck comfortable. Are their shoulders comfortable? Do they need any adjustment? Uh This is the ideal time to do those things. Uh You wanna avoid the patient now, uh reporting discomfort in their position when you're midway through the procedure itself uh is at this stage that once the patient is comfortable, this is when the drapes are placed. And uh we often offer, we often offer our patients some uh noise canceling headphones and they play music of their choosing. So this is uh a light distraction for them. And their uh option is supplemented by nasal cannula. Uh And we periodically check the patient, make sure they're comfortable, make sure they're responding appropriately and uh patients tolerate the procedure very well. Uh Doctor B will take the next uh on the be our benefits uh for performing this. Yeah. No, absolutely. And you know, as you mentioned earlier, you know, I, I think this procedure certainly requires more attention to the, to the patient. And I think the operating room which is already focused on the patient is even more focused on the patient. Um And so everything we do is really patient centered more than even uh the uh but when this is done, right, I think patients have a great experience. It ultimately leads to a decreased overall time for patients. Uh The procedures just move sleep seamlessly, um less overall post-operative pain, uh uh opioid use and better pain control. And you've kind of mentioned how uh we work to try to really get the patient's uh pain under control. And I think a big factor is that in that is that the minute the patient gets to the recovery room, they didn't have any uh general anesthetic so they really can start taking the opioids and um we already have gotten on top of their pain. We have all these other modalities that are really helping us control their pain. Um There's a also just a decrease overall emergency time since the patient didn't have any uh general aesthetic, they are not intubated. Uh Once you're flipped over, you're really just uh ready to get out of the room and there's not really any issues with that. And what I've, I've really found is that patients are actually, uh, more satisfied with, with the surgery itself. Um, you know, a, a lot of patients re remember a certain portion of it, they remember, you know, interacting with the anesthesiologist, they remember the music selection that they have and, um, you know, the overall care and, and I think that their, their participation in, in that, uh, leads to some improvement in their overall satisfaction the, the time to ambulate, um, is something that we really picked up on, uh, in, in some of the studies that we've done. What we found is patients that have had the, uh, spinal ambulate about seven hours more or earlier than patients that have had a general anesthetic. And then we've also found that patients that have had a spinal, have overall less post-operative fatigue. And I think that's a combination of decreased overall medications that are required, um, with surgery and, and then the fact that they are not getting general anesthetic in itself. And um so overall, I think patients do very, very well with this and fantastic. Um So we've, we've got some questions that have already started uh to come in. Um So the, the, the first one we got is uh how can I refer a patient to Mayo clinic for uh for this kind of procedure? Uh That's a great question. Um You know, we have um many uh of our physician reps that, that can, that can uh help facilitate that. And then also just referring just um reaching out to either myself or um uh any of my colleagues there um would, would be, would be an easy path. We can, I'm sure get you guys our information so that you can email us uh if you have any questions. Um so that we can put you um through that path. And I, I think there's also a link for um uh physicians that would like to refer as well. Right. Thank you. Um We have a, a couple of questions around the uh the patient experience um as they're coming in for uh th this type of surgery. Uh The first one is uh what is the experience for the patient during the surgery? I'm worried my patient will be nervous. Uh Do they watch a movie? I know you said you, they listen to, to music. Uh What are other, other things since they're gonna be kind of on their, on their stomach for, for that, that amount of time kind of draped off. You gonna take that. Yeah. Yeah. I mean, I think we can probably both, uh, hit on this. Oh, yeah. Um, it, it, it's the, it's an excellent question but the first part of that is patient selection and that, that's an important step. Uh, you wanna have somebody that's interested and motivated in, in pursuing the surgery. I in this fashion, if the patient does not wanna have it done this way, and then really, it's not something that we go there and we, we try to really sell it to them. Uh But if a patient is interested in having the procedure done in this fashion, I, I usually try to give the analogy to them. Um, a lot of these things are very similar to the orthopedic population where somebody comes in for a total hip replacement or a total knee replacement where they're getting a spinal anesthetic and a little bit of sedation. Um As far as experience, uh, they're really very calm during the procedure, we, uh run a little bit of lysis anxiolytic medication during the case. So, so some of the doses that I mentioned, these are not intended to uh make the patient unconscious, but they're intended for them to feel at ease. Uh We would also see in the holding area, that's part of the reason why we do the block in the holding area. How does the patient react to having the procedure done with a little bit of sedation? If the patient changes their mind, it doesn't wanna pursue that way and pursue the, the surgery under spinal. And we can always, uh, change that. Uh, most patients are very comfortable. Uh, we usually, uh, want them to be very important for them to be comfortable when they place in the prone position. So they're comfortable in that position. Obviously, patients that have claustrophobia, they don't uh like uh their face in the pillow would not uh prefer it, but most patients are OK with it. The best analogy that we can give them is when you go for a massage and you have that donut where you lay your head. Uh If you tolerate that, I don't, that you should be able to tolerate this. Uh The music is very helpful. Most of the patients just request music. Uh And because they periodically sort of drift off to sleep intermittently during the procedure and they usually pick something relaxing for them to listen to. Uh we do have the option to do virtual reality uh with virtual reality goggles. Uh I find that it's really not that helpful. Uh Sometimes it gets patients a little disoriented. Uh And most of the time they sort of wanna snooze off or just be pleasantly groggy during the procedure. Uh That is an option though that, that we can offer if they wanna wear virtual rea reality goggles in the prone position. Uh, Doctor Bal, uh, Doctor B, I think you really hit on a lot of the good points. Which is that, you know, I think there are some patients that, you know, when I first talked to them and give them, these options are a little bit anxious. But, you know, in, in my experience, you know, when I see the patients before surgery and then talk to them after surgery, they are actually pleased that they've had, uh, had it done. And I have actually, now we've been doing this long enough now that we've had patients that have had a general anesthetic previously. And now I had a spinal, um, and by far preferred having it done with the spinal. And, and I think again, you know, everything, as I mentioned earlier is really just focused on that patient comfort. So throughout the process, procedure, if at any point, the patient needs to shift or adjust or do anything, you know, they're able to communicate with us and say, hey, I, I need this, I need, I need my nose cracked. I need, I need, you know, and then the whole team is attentive to the patient so that we can make sure that uh, that experience, um, they get, they have a pleasant experience during this procedure. All right. So we have a couple of follow up questions to, to that. So if, if a patient is, you know, I, I going through the procedure if, uh, if it's gonna take longer than the, you know, the, the, the allotted time, um, what, what are the options for, uh, continuing the surgery if it, if it ends up taking longer than you thought? And the, the spinal is gonna start to wear off. Can they be converted to general anesthesia while the procedure is, uh, is underway? That's an excellent question and it's something that we needed to address and have a, a plan for ahead of time. So in our experience, the case taking longer than need to be converted to a general, even though there is an option that we do have, has not occurred yet, it doesn't mean that it can't happen, but you have to have that option available and you have to have a workflow and a close loop communication with the anesthesia team and the neurosurgeon about what that's gonna look like. Uh a few instances where it's sort of y you, you might run more in the situation where you're starting that cusp that the spinal is starting to wear off. And now you're at closing. Uh There's a couple of options there. Uh If bony work is done on the procedure, uh local infiltration on the skin itself is more than a sufficient to help with that. Uh Part of the procedure. Uh If there's still bony work that needs to be done, a local infiltration would not be sufficient uh one option that I think might have occurred maybe once or I can't remember more than twice. Uh where we basically offer uh to uh inject more local anesthetic into intrathecal space. In this situation. I would pass a local anesthetic and a on a sterile uh to uh doctor Boa and he would then himself would inject in the intrathecal sac uh approximately. So we use, we typically use uh 0.5% pubic case. So he would probably be injecting perhaps a half ac C uh of local anesthetic. And that supplements the spinal for a short period of time. This of course implies that uh the, the duration of time needed is not egregious. We're talking about, we were short at the end, the case is wrapping things up. Uh If something were to happen and uh the surgery is gonna become much longer, then it would have to be uh a discussion about maybe we should just come up with the anesthesia. Um at this point. Uh Doctor Ban. Yeah. No, I mean, uh you know, we've had great experiences with both, you know, you guys', uh uh you know, leadership and, and I agree with everything you said, you know, thankfully, we've not had any of those situations. I think the one patient you were referring to started feeling a little bit of the skin as we were closing the skin. And uh so, you know, really could just take care of it with local anesthetic and, and I agree, I think, you know, uh, and that, but that comes, goes back to that, um, point of, you know, you have to really be sure of the time it's gonna take for you to do that procedure. So, you know, you wanna make sure that you're pretty consistent in your time of it takes me this amount of time to do a TF it takes me this amount of time to do a laminectomy. Um So that, you know, even when something occurs, you have enough time to address that at the same time. Great. Thank you very much. Um So the next question is, uh, sleep apnea, patients are discouraged from awake procedures. What about moderate or severe COBD patients? That would be also a concern because those patients might have difficulty laying prone. Uh, we have not selected those patients for this procedure. Um, but, uh, they will probably not be ideal. Ok. All right. And, uh, why did Mayo clinic, uh look into pursuing awake spine surgery? Uh, were, uh, were there, were there any studies that that happened? Yeah, I mean, I think, uh for me, one of the biggest thing that, um I started noticing is that, um, you know, we would do these procedures on patients and, you know, if the patient is doing well, pain is gone. Uh But the one thing that consistently, every, you know, a lot of patient complained of was that fatigue that just was not, not ending and sometimes it took, took months and months to get over. Um, I would have patients come in six weeks, post stop, three months, full stop. And, you know, they just continue to explain. Hey, doc, uh, you know, the pain is better. My, I'm feeling great but I walk a block and I have to go home and take a nap and, you know, they just really could not get back to their, their life. And, and, and so, you know, that that's really what led to us starting to explore other options for, for these types of procedure. Um And so, you know, we, we were able to collaborate with our anesthesia team and, and put this program together. Great. Thank you. So how would you describe the recovery process for a patient? And you know, how soon can someone return to work or, you know, regular activities, you know, um from the activity standpoint, uh the restrictions, the there are, there are restrictions that you're gonna have after any type of fusion surgery and those restrictions are to allow things to heal properly. And, and, and so those restrictions remain regardless if you had it done awake or if you had it during uh uh had it done under general anesthetic. You know what I would say is that by far um by one month after surgery, um the patient's limitations are of me, right? And so the restrictions that I put on them is really what they're asking me about when we're talking about when we're having a follow up visit is when can I start doing more because I feel great. Right. And, and, um, so, so that, that's the, the part from that, from that standpoint, but in regards to returning back to work, it really depends on a combination of things. It depends, it depends on the type of work that they do. Right. If, if it's gonna be something that is, uh, uh, you know, they'll be breaking those restrictions from, then it's gonna take them a little bit longer to, to return to work. They can certainly return to work light duty. Um, but, you know, really a, at that point, if the patient, if the patient has a, uh, a desk job, for example, they, they can return back to work within a week or two after surgery. I've had a patient return back to work two days, post op after a fusion. Um, and, but again, he had a, a desk job and most of his work just required him to walk around. And so, um, he felt great enough, good enough after a, you know, a fusion surgery flew in, had surgery, went back home the next day, um, on day, on the day after, went back to work. All right. So that, uh, actually goes, uh, right into one of our other questions. So how can, uh, can you accommodate patients from out of state, obviously that the answer to that is yes. And if they are from out of state, how long do they need to stay in the area for recovery sla slash follow up visits? Uh, if any, and you know, is it, how can, uh, how can I monitor the follow up care? Uh How can they follow, how can they monitor their follow up care in, you know, the local, their local area once they're gone back to wherever they're from? Yeah, that's uh that's another great question. Uh You know, we, we certainly can accommodate all patients to try to organize their visit in the, whether that everything is done at once, obviously with. Um um now it makes things even easier. Um But, you know, typically for these type of surgeries, um really a patient does not need to stay around for too much longer as long as they are feeling good. Um They usually spend, they spend a night or two in the area and then start to head back home if they want. Um in regards to follow on really, those are things that I can, I can do even from here because a lot of times, um you know, we just need some x-rays so they can get the x-rays, send it back. Obviously, I wanna see patients back at some point and, and so, uh we, we work with patients to schedule a time that works best for them, but with video visits with tele or with uh phone visits, we can usually handle all the things that we need to handle. Um even from here. But I've also collaborated with local neurosurgeons, uh and orthopedic surgeons um who have sent their patients here and they wanted to follow the patients out and we, you know, we work together to, to make sure that we do what's best for the patient. Great. And then, so what are the, what are the conditions that are uh that this type of surgery benefit the most? So what are your, what are, what are the, the top uh the top uh procedures that you, you're doing for this kind of procedure? Yeah. So, I mean, um I think the patients that benefits benefit the most from this type of procedure are really anyone that's having a one or two level fusion surgery, um a Laminectomy or Laminectomy and dissect toy. And, and so, and, and obviously, we try to always try to do those procedures minimally invasive. Um So I, I think anyone undergoing those procedures would benefit the most from, from this because th those are things that typically would, would have required a general anesthetic. It can also fit in that time frame of the procedure itself. Um So uh what kind of patient education is provided prior to surgery? And how can I help my patient be best prepared? Doctor Barley, you wanna, of course, uh the patient education occurs uh, from my understanding, uh, when, during the neurosurgical visit, they're, they're giving information about what to anticipate and the options, uh, to undergo the procedure. Uh, it's important that when we see them when they come to the preoperative clinic, but also when they come to the day of surgery, this is not something you wanna tell the patient for the first time and present them as an option so that you wanna give them the opportunity to kinda digest the information a little bit. Uh Once we see them in the holding area, we go through the plan and it's very similar to the presentation that we did. You know what to anticipate today, we're gonna give you some pain medication and some anti nausea medication ahead of time. We're gonna do a nerve block to help you with pain control in anticipation that spinal wears off. Uh A lot of patients might have had a spinal before. Uh, some patients might have had them for uh labor and delivery, uh reasons. Some patients might have had it cause I've had uh prior orthopedic work done in their lower extremities, hips and knees. So a lot of them are familiar with what it's like, you know, to have a spinal and have a surgical procedure done and it's an opportunity to, uh, to answer questions. Uh Doctor Biaa can talk a little bit more about this. But I think we also have a, a patient education video that I, uh, their team refers them to, to sort of see what does it look like. What is the overall experience like? And, uh, in my experience when the patients arrive in the holding area, the day of surgery, they're, they're all mentally prepared, they have an idea of what to anticipate. All right. So I, if ho how do I know that my patient would be a good fit for this? Well, the, the first step would be asking them, would they be interested in, in approaching the procedure as such? The other thing is gonna be just uh assess the patient? You know, you can, uh the main concerns that we have is the patient that due to their body habit is they wouldn be able to be comfortable to lay flat. And, and you can tell, you know, patients that have severe sleep apnea patients that have, uh somebody mentioned and what if they have bad COPD if somebody is walking around with an oxygen tank, it's probably not the best patient. You know, this is more optimized for the patient that already has uh uh highly motivated, has a good level of mobility and they just kinda wanna get back on their feet. Uh So those are the main things to assess. Uh And if you feel that it's appropriate to have the surgery, uh this way, then of course, we will then do our part to educate the patient further and re evaluate them and assess them uh before we move forward. Yeah, I think one thing that patients understand, uh at least a lot of patients have had some sort of grasp in their mind is undergoing a colonoscopy, the, the state of mind that they're gonna be in undergoing a colonoscopy. And then I think, you know, when we explain to patients that, that, yeah, you know, you're not gonna be fully asleep or you're gonna be in that, in between stage where, you know, we're communicating with you and, but at the same time, you're nice and comfortable. I think patient get, get a better grasp of what, you know, things will look like. And you know, most patients, uh like you said, is, you know, just really just assessing whether or not um they can lay on their stomach or whether they can. Um And whether or not they can uh uh uh be comfortable in, in, in that position would be, is a great uh um uh first step to understanding or not, whether they would tolerate it. All right. So this question is actually coming for me cause I now I, now I wanna know. Um So if you're in that, that twilight kind of state, does the patient have much memory of the procedure itself? I'll be, I can answer that and I can follow up with, with the doctor Boda's comment. Uh So colonoscopy, sedation for colonoscopy can be a different experience for different patients depending on what that practice looks like. And what agents are they using i in some uh settings, they're using heavy doses of propofol to do the procedure um where the patient is essentially under d anesthesia, but they don't have a secure airway. That is not what our goal here he here is for this case, that would be uh a little concerning uh some colonoscopy practices, do something of uh a little bit of midazolam, a little fentaNYL. Uh And the patient sort of has this kind of in and out in and out sort of experience that they want to describe it as twilight where they remember some things and they don't remember other things. I remember they were talking about something, but then I don't really remember what happened after that. Uh That is more of the experience that they will anticipate when they have this procedure. Obviously, it's gonna vary from patient to patient. We're all very different. We all respond very different to uh anxiolytic medications. Uh But generally speaking, you know, when I ask him in hindsight, you know, what was your experience like? They'll, they'll still remember a lot about the initial positioning and putting on the headphones, which we want them to cause we wanna make sure that they're comfortable. Um And then the procedure itself during the procedure is sort of in and out, in and out. They remember a noise. They remember a little bit of this or maybe somebody said something to, you know, when we interact with them. But it's a blur, uh, during that part. And then the, the, the last, then what they end up remembering at the end is like, because we turn the sedation fairly, uh, turn it off fairly early. You know, you know, when the doctor boti is, is closing skin, we, we turn everything off. So by the time the drapes come down, they're fully awake. So they'll remember that they're comfortable, they don't feel anything but they'll remember that. And uh the purpose of that is that we'll make sure they're comfortable. And one of our goal is that when they do arrive in the uh recovery area, uh they're awake, they're lucid and at this point, we can start advancing their diet, you can give them some clear liquids, give them some crackers, really get them ready for them to be able to uh bypass that period of time where they'll need intravenous analgesics. They can just take some oral analgesics and really feel like they're in control of the recovery uh when their recovery area. Does that answer your question, Alan, it does very well. Thank you very much. I, I just wanna also uh mention a quick note, um as you talked about, you know, the, you know, advancing the diet, you know, I think that's the other benefit that really we've not touched on uh on, on this uh type of procedure, you know, you know, with general anesthetic. One of the problems that a lot of patients have is post-operative nausea and vomiting, uh, which was a lot of patients and that makes it a really intolerable thing. And so for spinal, since they did not get a general anesthetic, most patients, you know, a good number of patients don't really have that after, after the procedure. Well, those are all the questions that have come to us so far. Um, Do you each have any sort of uh final statements before we wrap up today's program? Kingsley? You wanna take it away? Yeah. No, I just wanna thank you guys for um tuning in and thank you guys for the uh questions of putting this together. You know, I, I think this is really the um the next stage of uh spine care for patients. I, I think uh it's gonna, we're gonna continue to see this grow. It's certainly has become a very big topic and uh you know, national neurosurgery meetings. And um and I think uh there continues to be, you know, many papers that are published uh showing the benefit of this um compared to a general anesthetic for these uh procedures. So I think it's gonna continue to grow and uh we're gonna continue to see uh more and more uh places adapt this uh protocol. Thank you very much. Um Same pleasure to be here. Uh This was a lot of fun. Um I wish I could see an audience to see who, who the ons is today. Uh For the neurosurgeon, the anesthesiologist there in the audience, I would say this is something that you're interested in adopting in your institution. Uh I would say the first step is to really have good communication between the surgical and anesthesia side. Um It's not as simple as, oh, we'll just do spine surgery under spinal. Um You, you really need to put it all together. It's from patient selection to education. It's really having a good comprehensive plan of what their uh analgesic profile is gonna look like. What's the plan for this patient? And you want to use the patient's um the advantage of doing the patient, the, the case under spinal and having the patient lose it at the end of the case, you really want to use it to your advantage. You really want to take that opportunity to really facilitate that recovery to encourage mobilization. Uh I really feel that uh if you, if it's just a matter of all, you just do the surgery under spinal, but then they just lay in bed and recovery area and they're just getting doses of IV opioids. I've, I'm doubtful that you're gonna see some of the benefits that, that, that we have seen. So it's really engaging the entire process and uh really working together as a team. That's, that's where I think that's the, the main uh point. Thank you. Awesome. Uh Thank you both. Very much. Uh Thanks everybody for joining and I hope you, everyone has a great rest of your day. Thank you.