A kid-friendly (and opioid-sparing) scoliosis surgery

Opioids are a necessary part of surgery, but they come with many downsides — addiction risk being the most worrisome. So, when Vishal Sarwahi, MD met a young patient with a history of opioid misuse who needed scoliosis surgery, he knew he had to find another way. On this 20-Minute Health Talk, he shares his pioneering efforts to reduce reliance on opioids in pediatric scoliosis surgery, as well as the technical advances he has brought to the operating room that are making it possible — something he calls the Rapid Recovery Protocol.  

Dr. Sarwahi is director of Northwell Health's Center for Minimally Invasive Scoliosis Surgery and the Center for Advanced Pediatric Orthopedics at Cohen Children’s Medical Center.

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a pioneer in thefield of pediatric scoliosis surgery.
For me, scoliosis is my passion.
This is what I live and eatand breathe every day, essentially.
SoI listen to my patients, I talk to them.

(00:22):
Three years ago,
I had two kids who came to me withscoliosis who already had history
of opioid misuse.And around this time, we all know,
opioid epidemicwas becoming a major problem.
Of course, parents were concerned.
This presented a dilemma.
Orthopedic surgeries like scoliosiscorrection are painful procedures,

(00:44):
and patients receive large amountsof opioids to help them recover.
Often,they leave the hospital with 15 days to three weeks of the highly potent,
highlyaddictive painkillers. Listening to these concerned parents,
he knew he had to find another way.
If you connectwith your patient, they teach you.

(01:06):
You learn a lot from them.
And what he learnedfrom these two cases inspired
a major advance in scoliosis surgery,
one that has ledto not only less invasive techniques and faster recovery times,
but an astonishing80% decrease in the amount of

(01:26):
opioids givento kids during and after surgery.
Hello, andwelcome to 20 Minutes Health Talk.
I'm Sandra Lindsay. Fortoday's episode, we sat down with Dr.

(01:48):
Sarwahi to learn abouthis pioneering efforts to reduce
reliance onopioids in pediatric scoliosis surgery,
as well as the technicaladvances he has brought to
the operatingroom that are making it possible,
somethinghe calls the rapid recovery protocol.

(02:09):
Dr.
Sarawahi isdirector of Northwell Health center for Minimally Invasive Scoliosis
Surgery andthe center for Advanced Pediatric Orthopedics at Cohen Children's
medical centerswho are given opioids for surgery are

(02:35):
at a higherrisk of opioid misuse later in life.
Even more troubling,
it takes just five days to developan addiction to this class of drugs,
whichinclude prescription painkillers like Oxycontin and Vicodin,
some of the strongest on the planet.

(02:56):
While dangerous, opioidsare a necessary part of surgery,
particularly major orthopedicoperations like those done to
treat severe scoliosis, which Dr.
Sarawahi performs daily.
First andforemost, it is a very safe surgery and a very successful surgery,
especiallyin teenage years. So I would put it almost 99% safe, 99% successful.

(03:21):
What isroutinely or what commonly is now being done, we are putting screws.
You heard it correctly. It'sscrews, and we put rods in the spine.
Sowe're putting screws slightly smaller than my little finger, my pinky finger.
So two screws at each bone notthe whole spine, is fused, obviously.
We only usually fix the curve, andthen we put in a rod, left side rod,

(03:43):
and right side rod. The rodsimagine the screws are like anchors,
and the rods are the ones whichbasically straighten the spine out.
I do a lot of these, soI take about two and a half, 3 hours.
But on average,people take about five, 6 hours.
30% of those diagnosedwith scoliosis need treatment.
Just 10% need surgery.

(04:04):
So, scoliosis is a curve of your spine.
It's not just a curve.
It's also atwist. The twisting is very important,
andit happens mostly in teenage years,
around the time when they gothrough puberty and they grow a lot.
That's whenthe back starts curving and twisting.
Unfortunately,it's more frequently in girls.
Andthat twist causes another problem.

(04:26):
And when the whole bodytwists, the ribs stick out in the back,
what is called as a rib hump.
And that'show most pediatricians and patients
will notice the ribs are malformed or.
Deformed, something that Dr.
Sarwahi said is most oftencaught between ages ten and 15.
When children hit a growth spurt, it.
Is obviousyou look at the back, you will see it,

(04:49):
especially if they have tight clotheson or if they're in the swimsuits,
you will see it. If you look at the backand see something is sticking out,
or one shoulder blade is sticking out,
or one shoulder is slightly higherthan the other, hips are asymmetric.
Bringthem to the doctor left untreated, any case that would require surgery,
meaning a curve of more than 40 or50 degrees will continue to increase

(05:13):
one or two degreesevery year for the rest of your life.
Dr. Sarawahi explained, if I'm 20.
Years of age andI have a 50 degree curve, in 20 years,
that curve canbe anywhere from 70 to 90 degrees.
Now, that's a big curve.
Can we fix it at that age?
Sure enough, we can.But at 20 years of age, it is 99% safe,

(05:34):
99% successfulsurgery. Same surgery at 40 years of age is only 70% successful.
Not just that, it's a big curve.
So you will get less correction.
Not just that,
that curve is big enoughthat it's going to push on your lungs
and compromise the lungs.So your breathing goes down a bit,
yourlung functions get compromised,
and the fear isthat it will start affecting your heart,

(05:56):
it usually will not kill you,
but it will definitelycompromise the quality of your life.
Thereare some studies actually coming out of Italy, an untreated scoliosis,
where there is about 20% mortalitybecause of heart and lung problems
later on at that age.
So obviously,you don't want to be there.
The best thing is to get it fixed.
Correcting this rib hump, Dr.

(06:18):
Sarwa, he told us,
could require shaving down therib or even breaking and removing
one or several toreturn the body to a normal shape.
And that hurts. Crack ribs hurt.
Withsuch a major surgery, controlling pain is critical to a patient's recovery.
Opioids are crucial, especially for badpain, not your routine ankle sprain.

(06:42):
This is surgical pain. This is painful.
If I'm cracking your ribs,if I'm cutting your bone, it is painful.
I won't lie to you.
That'sthe first thing that these teenagers are concerned about, is pain.
Essentially, pain delays recovery.
Pain can becomechronic if you don't treat it properly.
So for the rest ofthe life, they'll be experiencing pain.
But opioids, given atthe right dose for the right duration,

(07:05):
can manage it safely. Problemis, as we all know, they are addictive.
Opioid addictionaffects all ages and communities and has contributed to drug
overdosesbecoming one of the leading causes of unintentional death in the US.
Tragically,the risk to kids is only getting worse.

(07:28):
The CDCreported a 94% spike in overdose deaths among kids 14 to 18 years
old from 2019 to 2020.
That numberincreased 20% from 2020 to 2021.
About 90%of those deaths involved opioids,

(07:51):
accordingto the CDC's state unintentional drug overdose reporting system.
A major factor driving this trendhas been the widespread availability
of fentanyl, which is50 to 100 times stronger than heroin.
United States has lostmore people to the opioid epidemic.

(08:13):
Andthis is not just prescription combined everything fentanyl and everything
illegal and everything,than in the entire World War II.
I mean,to me, that is a gut wrenching fact.
Thisproblem started. Dr. Sarwa, he said,

(08:34):
when the idea becamegetting pain down to zero, pain.
Was considered the mostimportant thing in terms of recovery.
Notjust surgery, anything. Sprain even getting a wisdom tooth removed,
essentially.
sotrying to avoid pain became, at that time, the most important directive,

(08:55):
not justfrom patients or parents, but also from the government or the CDC.
Everybodywas talking. FDA was talking about pain, managing pain, managing pain.
And I think weran away with it for quite some time,
and with the right intention.
Unfortunately,this problem continues today.
In general, the standardall over the country is lots of opioids.

(09:17):
They dogive this thing called the PCA, which is patient controlled analgesia,
so that we attachyou to an IV line with a pump which
keeps pumpinga basal rate, a fixed, constant rate,
everyhour for two days in the hospital for five to seven days on an average,
and they wouldgo home with 15 to days to three weeks of oxy and other opioids.
The problem with all that is whenyou get too much of morphine, a,

(09:39):
the pain never goes down to zero.
But then once we started realizingthat there are problems and
people are getting veryaddicted very quickly and very early
people start asking questions,
are we overdoing this?And slowly, the change happened.
Aroundthis time, two patients came to Dr.

(10:00):
Sarwahiin need of scoliosis treatment.
In each case, surgery would becalled for, but there was a problem.
Both had a history of opioid misuse,
which the parents let him knowfaring what might happen if their
child was givenlarge amounts of opioids for surgery.

(10:21):
Whenthese kids came to me there was a comeback of duramorphic medicine.
Duramorph isa type of opioid given as an injection
in the spine to control severe pain.
For context,
it is ten times more potent than anepidural and has been routinely used

(10:42):
in muchsmaller doses, called microdoses, during C section deliveries.
Reading aboutits use in other types of surgery, Dr.
Sarawahi wondered if thesetwo patients, and more broadly,
all scoliosissurgery patients, could benefit.

(11:02):
Now, the beautyof Duramorph is that it's hydrophilic.
It loves water, essentially,
so it gets attractedtowards anything that is watery.
And CSF, that isa spinal fluid that we have is watery.
So it gets dispersed along the wholespine, top to bottom, essentially,
because the.
Medication remains within thecerebrospinal fluid for several hours,

(11:24):
patients wouldn't need as higha dose to control pain from surgery.
In 2018, Dr.
Sarawahi presentedthe idea to his pain management team at Cohen Children's
Medical center, includingthe hospital's chief of anesthesia, Dr.
Michelle Cars.
A lot of conversations. Weput a team together, along with Dr.

(11:47):
Carrsand the other pain management team of our physical therapists,
social workers, nurses,that this is what we're going to do.
and we said, this is a trial thing.
Dr. Sarwahi decidedto begin a trial using duromorph.
He kept patientcontrolled anesthesia on standby,

(12:08):
but feltthat the patients wouldn't need it.
There was just one unknown.
The question came down to the dose.
What would be the right dose?
Obviouslythe higher dose puts you at high risk of respiratory depression.
So wedid not want to go to a higher dose.
In the pediatric surgery, theyhad tried two to four micrograms.

(12:29):
We wanted to bring it down.
Dr. Sarwahi landed on1.5 micrograms for his two patients.
For scale, 1 μgis equal to one 1000 of a milligram.
So for a 90 poundchild, that would be 61 micrograms.

(12:49):
By comparison,
patients on PCA received 25 to 50milligrams of morphine IV per day.
Started with two cases. Theydid well, then we started with ten,
then we reviewed it, then went to 50.
We reviewed, and thenpretty soon, it became standard.
So we slowlystarted putting that as a protocol.

(13:12):
Butinitially, there was resistance as it.
With anything new. I'm like, no,
it is adose which is given at the right place
becauseit primes your nervous system.
and since then, we have neverlooked back, and we have done,
I have now 500kids who have been treated this way.
This approachwas the first step in what Dr.

(13:35):
Sarawahicalls the rapid recovery protocol.
So, rapidrecovery protocol started elsewhere.
Other places started doing it maybea year before we came up with this.
We were initially hesitant becausethey still use PCA for about a day
and a half. And to me, that wasstill 50 milligrams extra morphine.

(13:56):
So we were hesitant in doing that.
So we put together our own rapidrecovery protocol, which is basically,
they go home in three days.
So an hour afterthe surgery, they can start eating,
which is not true forthe PCA because they are nauseous.
Theycannot eat for almost a day or two.
Mykids can start eating an hour later.
That means they can swallow pills,

(14:18):
so I don't haveto give them injectable morphine.
And we dependa lot on tylenol and edible alongside.
Of course, we do have, forthree to five days, some oxycodone.
but mostly not much of injectable.
Compared to patients receiving PCA,
thosebenefiting from the rapid recovery protocol received nearly one 10th of

(14:39):
the amount of morphineand were prescribed half the amount
of oxycodone post surgery,according to a 2021 paper Dr.
Sarwahipublished in the journal spine.
one night in theICU, second day, they're sitting up.
Third day, they're climbing stairs.
Usually they go home in three days.
And when I send them home.
I send them home on three to fivedays of some oral pain medications.

(15:03):
Themicrodose does require surgeons to not only think differently about pain
management,but to thoroughly prepare their patients on what to expect.
I always educate my patients.
I tell them, hey,
expect the pain to be around threeto four on a scale of zero to ten.
a lot of time when you prepare them.

(15:24):
kids are smart, they understand,
they listen and their expectationsare accordingly fine tuned.
Essentially, we almost decreasethe opioid consumption by 80%,
and I'm very proud of it.
It's a big, big thing.
80%less opioids and better pain control.
The journey still continues. Sothis is not the end of the duramorph.

(15:51):
We are now looking at if thereis a difference, and actually, there is.
If the duramorph is given beforesurgery by the anesthesiologist,
before they go under anesthesia,or before even I make an incision,
versusif I give it at the end of the surgery,
thatthree hour difference makes a huge difference in the amount of opioids.

(16:12):
So ifthey get injection before the surgery,
thenervous system is already primed, so they wake up much better,
requiring less pain medication.
Sincepublishing these findings in 2021,
he and his teamcontinue to update this technique
and explorenew ways to improve the surgery.
Technology hasevolved. Our technique has evolved.

(16:34):
So in a classicscoliosis surgery, we open your back,
you moveyour muscles away, and we have to expose the entire bone, essentially,
and then we reattach it.
But moving muscles,
if anybody who has had asprain of the ankle or the knee and a
major sprain will attestto that, it's a very painful thing.
Now, imagineyour whole back has been sprained.

(16:56):
but the same surgery, I have beendoing it in a less invasive manner.
I don't strip yourmuscle the same way, so essentially,
I'm preserving your muscles.
So I find the natural planethat exists between those muscles.
So imagine if I keep my fingers nextto each other and I'm just separating
those fingers out insteadof chopping those fingers away.

(17:19):
So I just separate those.
Your muscles are still attached.
I findthe natural plane that exists, and through that plane, I put my screws.
So obviously, less painful,less blood loss and faster recovery.
In fact, the study that we publisheda few years ago, we found, like,
almost 90 9% of themdid not need a blood transfusion,
which is compared to if 20% to 30%patients require blood transfusion,

(17:44):
is a major win. The downsideis it does take a little bit longer,
but withexperience, this should decrease.
Also,
this minimally invasive approachstarted taking shape ten years
ago and also takes intoaccount the scars left by surgery.
So scoliosis,it depends on the type of the curve.

(18:05):
Sometimes you have two curves.
Sometimesit can be your whole back.
But insteadof now one long incision back,
I'm gettingaway with three non contiguous,
sothey're not connecting to each other.
incisions.so if you have a swimsuit on,
probablyyou will not notice a long incision.
Youjust might notice a tinier incision.
But it's not about the incision, right.

(18:26):
It is more aboutpain and long term benefits of it.
Sowe realized, know, this approach has been in place for quite some time,
and we just combined two plustwo together, and we came to this.
The latest evolution to. Dr.
Sarwahi'sapproach aims to improve accuracy when placing screws during scoliosis

(18:48):
surgery. Andhe's doing it using a combination of technique and technology,
or TNT for short.
Now,I've put almost 70,000 screws now.
and you always worrythat what is happening if, by chance,
the screws are misplaced?
And with goodreason. In typical scoliosis surgeries,

(19:12):
screws aremisplaced around 30% of the time.
Butwhen Dr. Sarwahi checked his work.
My accuracy rateconfirmed on cat scan is about 93%.
Luckily, most of the screws are lyingnext to the muscles or ligaments,
and they'renot endangered. But you have to understand what the risks are.
so I toldyou, we put screws into the spine,

(19:35):
and the screws actually gofrom the back of the spine through
the middleof the spine to the front of the spine.
The problem is thatwhen we're putting the screws in,
we are not seeing the front ofthe spine or the middle of the spine.
We just see the back of the spine.
Onewrong move, he says, and surgeons could damage the spinal cord,
lead into paralysis, or evenvital organs like the heart and lungs,

(19:58):
which could be deadly.
So you have to do this either underx ray vision, which is fluoroscopy,
lots of radiation or just by field.
so technology hasbeen evolving to try to help surgeons
putscrews in a much more safer manner.
We havenavigation technology that has been around for at least ten years or so,

(20:23):
where people aredoing CAT scans before the surgery.
And based on that, then youuse navigation during the surgery.
So think of it like navigation,your car navigation, right?
I mean, you gohome every day you drive, every day.
You know the roads,
but still you switchon your Google Maps because it
may tellyou the faster way of reaching there.
The problem with that, he told us,

(20:44):
was you still didn't knowif your screws were placed accurately
because scans were takenbefore placing the screws, not after.
You'Re presuming that yourscrews have been placed accurately.
He acquiredan intraoperative CT scan machine called Arrow and began taking
scansduring and after to confirm the placement of screws were accurate.

(21:09):
But he found another downside.
Whenwe started adapting this technology
mytwo and a half, three hour surgery became a four or five hour surgery.
And you may say, well,it doesn't matter, but it does matter,
because longer surgery meansmore anesthesia for the patient
more chance ofblood loss, more chance of infection.
why would I want. And more pain.

(21:29):
Why would I want that?
So wecame up with this thing called TNT,
which is a shortform for technique and technology.
I have thesurgical technique of putting screws.
I've been doing it all these years.
I'm pretty facilewith it, so I can put those screws.
As I start putting screws,
there will be one ortwo areas which will be challenging.
I can skip those, and I continueputting the remainder of screws.

(21:52):
And onceI'm done, I bring in my CaT scan.
It takestwo minutes for the CaT scan to spin.
I see all my previously placed screws.
I adjust them if I need to.
And those one or two that I'veskipped, I can now use navigation,
and pretty soon,
I've been able to put it backto two and a half hours and with
better accuracynow. So that approach we call as TNT,

(22:13):
it is as if we are combining allthese things together and not only
making surgery safer, but alsomore efficient and outcomes better.
Dr. Sarwahi is now studying theeffectiveness of his TNT approach.
We are the only placein the country which is doing it.
This techniquegives me best of both worlds.

(22:34):
Aswe wrapped up our conversation, Dr.
Sarawahi saidparents and patients are thrilled to
hear thatopioids are not so heavily relied on.
Parents are asking for it.
kids have become smarter.
They are on board with this, butparents are demanding it equally.
While many continue to use PCA andprescribe opioids for surgical pain,

(22:59):
he said he sees a positivetrend of surgeons looking for ways
to reduce their relianceon the dangerous painkillers.
Be a skeptic, not a naysayer.
You should be a healthy skeptic,not everything is absolutely correct.
and absolutely right. In medicine,sometimes things become a fad.

(23:20):
but if there is enough evidence,parse the evidence, look for it,
and talk to the guys whohave done it, and they'll tell you,
because there are nuances to this.
not everything
is as successfullyreproducible everywhere.
So, for example,
a TNT approach
not everybody will be able to do it,

(23:41):
because you have to havethat experience of putting screws
in that way kind of thing.
If you're not, I will say,
stickwith the navigation because you don't want to harm first, do no harm.
Right. But for the duramorph, theopioid thing, that is not that difficult.
if you are hesitantdoing it, ask your anesthesiologist.
They'll be able to help you.
People are willing to help.

(24:02):
You have to seek collaboration.
Education is constant.
What youhave learned ten years ago probably is not going to be accurate today.
It has to change. We have to change.
Reflecting onthe many advances he has made to
scoliosissurgery in the last decade, Dr.
Sarawahi thoughtback to those two patients who

(24:23):
startedhim down this path ten years ago.
Hadit not been for those two patients,
I would still probablybe practicing what others are doing.
So
my approach is, I listen to my kids.
That does it for this episode.

(24:43):
Thank you to our guest, Dr.
Vishal Sarwahi,
for sharing his inspirationalstory on behalf of our podcast team.
Thank you for listening.Until next time, I'm Sandra Lindsay,
and this has been anotherepisode of 20 minutes health Talk.