Dr. Sarwahi: 0:00
My approach has always been how can I make it better? And it may be one tiny step, but anything that can make it better.

Sandra Lindsay (Host): 0:07
That’s Dr. Vishal Sarwahi, a pioneer in the field of pediatric scoliosis surgery.

Dr. Sarwahi: 0:14
For me, scoliosis is my passion. This is where I live and eat and breathe every day, essentially. So, I listen to my patients. I talk to them. Years ago, I had two kids who came to me with scoliosis, who already had a history of opioid misuse. And around this time, we all know opioid epidemic was becoming a major problem. Of course, parents were concerned.

Sandra Lindsay: 0:36
This presented a dilemma. Orthopedic surgeries like scoliosis correction are painful procedures, and patients receive large amounts of opioids to help them recover. Often, they leave the hospital with 15 days to three weeks of the highly potent, highly addictive painkillers.

While dangerous, opioids are a necessary part of surgery, particularly major orthopedic operations like those done to treat severe scoliosis, which Dr. Sarwahi performs daily.

Dr. Sarwahi: 3:12
First and foremost, it is a very safe surgery and a very successful surgery, especially in teenage years. So, I'd put it almost 99% safe, 99% successful. What is routinely or what commonly is now being done, we are putting screws — yeah you heard it correctly, it's screws — and we put rods in the spine. So, we're putting screws slightly smaller than my little finger, my pinky finger. So, two screws at each bone. Not the whole spine is fused. We only usually fix the curve. And then we put in a rod, left side rod and right-side rod. Imagine the screws are like anchors, and the rods are the ones that basically straighten the spine out. I do a lot of these, so I take about two and a half, three hours. But on average, people take about five, six hours.

Sandra Lindsay: 3:55
Thirty percent of those diagnosed with scoliosis need treatment. Just 10% need surgery.

What is scoliosis?

Dr. Sarwahi: 4:04
So scoliosis is a curve of your spine. It's not just a curve; it's also a twist. Twisting is very important, and it happens mostly in teenage years, around puberty and when people grow a lot. That's when the back starts curving and twisting. Unfortunately, it's more frequent in girls.

Sandra Lindsay: 4:23
And that twist causes another problem.

Dr. Sarwahi: 4:26
When the whole body twists, the ribs stick out in the back, what is called the rib hump. And that's how most nutritionists and patients will notice. The ribs are malformed or deformed.

Sandra Lindsay: 4:36
Something that Dr. Sarwahi said is most often caught between ages 10 and 15 when children hit a growth spurt.

Signs of scoliosis to look out for

Dr. Sarwahi: 4:46
It is obvious. If you look at their back, you will see it, especially if they have tight clothes on or if they're in swimsuits. If you look at the back and see something sticking out, or one shoulder blade is sticking out, or one shoulder is slightly higher than the other, or if their hips are asymmetric, bring them to the doctor.

Sandra Lindsay: 5:02
Left untreated, any case that would require surgery — meaning a curve of more than 40 or 50 degrees — will continue to increase one or two degrees every year for the rest of your life, Dr. Sarwahi explained.

Dr. Sarwahi: 5:20
If I'm 20 years of age and I have a 50-degree curve, in 20 years, that curve can be 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 a 99% safe, 99% successful surgery. 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 enough that it's going to push on your lungs and compromise the lungs. So, your breathing goes down a bit, your lung functions get compromised, and the fear is that it will start affecting your heart. It usually will not kill you, but it will definitely compromise the quality of your life.

There are some studies actually coming out of Italy on untreated scoliosis where there is about 20% mortality because of heart and lung problems later on at that age. So obviously, if you don't want to be there. The best thing is to get it fixed.

Sandra Lindsay: 6:15
Correcting this “rib hump,” Dr. Sarwahi told us, can require shaving down the rib, or even breaking and removing one or several to return the body to a normal shape.

Dr. Sarwahi: 6:29
And that hurts. Cracked ribs hurt.

Dr. Sarwahi: 8:09
The United States has lost more people to the opioid epidemic, I mean, not just prescription, combined, everything, fentanyl and everything, illegal and everything, than in the entire World War II. That is, to me, that is a gut-wrenching fact.

Sandra Lindsay: 8:31
This problem started, Dr. Sarwahi said, when the idea became getting pain down to zero.

Dr. Sarwahi: 8:39
Pain was considered the most important thing in terms of recovery. Not just surgery, anything. A sprain, even getting a wisdom tooth removed, essentially. So trying to avoid pain became, at that time, the most important directive, not just from patients or parents, but also from the government and the CDC. Everybody was talking about pain, managing pain, managing pain. And I think we ran away with it for quite some time. And with the right intention.

Sandra Lindsay: 9:09
Unfortunately, this problem continues today.

Dr. Sarwahi: 9:13
In general, the standard all over the country is lots of opioids. They do give this thing called the PCA, which is patient controlled analgesia. So, we attach you to an IV line with a pump, which keeps pumping a basal rate, a fixed constant rate every hour for two days; in hospital for five to seven days on average. And they would go home with 15 days to three weeks of oxy and other opioids.

The problem with all that is when you get too much of morphine, A) the pain never goes down to zero. But then once we started realizing that there are problems and people are getting very addicted very quickly and very early. People start asking questions: Are we overdoing this? And slowly and slowly the change happened.

Dr. Sarwahi's epiphany

Sandra Lindsay: 9:56
Around this time, two patients came to Dr. Sarwahi in need of scoliosis treatment. In each case, surgery would be called for. But there was a problem: Both had a history of opioid misuse, which the parents let him know, fearing what might happen if their child was given large amounts of opioids for surgery.

Dr. Sarwahi: 10:21
When these kids came to me, there was a comeback of Duramorph in medicine.

Sandra Lindsay: 10:27
Duramorph is a type of opioid given as an injection in the spine to control severe pain. For context, it is 10 times more potent than an epidural, and has been routinely used in much smaller doses -— called microdoses — during C-section deliveries. Reading about its use in other types of surgery, Dr. Sarwahi wondered if these two patients — and more broadly all scoliosis surgery patients — could benefit.

Dr. Sarwahi: 11:02
The beauty of Duramorph is that it's hydrophilic. It loves water, essentially. So it gets attracted towards anything that is watery. And CSF, that is a spinal fluid that we have, is watery. So it gets dispersed along the whole spine, top to bottom, essentially.

Sandra Lindsay: 11:18
Because the medication remains within the cerebrospinal fluid for several hours, patients wouldn’t need as high a dose to control pain from surgery. In 2018, Dr. Sarwahi presented the idea to his pain management team at Cohen Children’s Medical Center, including the hospital’s chief of anesthesia, Dr. Michelle Kars.

Dr. Sarwahi: 11:44
A lot of conversations we had, we put a team together along with Dr. Kars and the other pain management team of a physical therapist, social workers, nurses, that this is what we're going to do. And we said, this is a trial thing.

Sandra Lindsay: 11:59
Dr. Sarwahi decided to begin a trial using Duramorph. He kept patient-controlled anesthesia on standby, but felt that the patients wouldn’t need it. There was just one unknown.

Dr. Sarwahi: 12:13
The question came down to the dose. What would be the right dose? Obviously, the higher dose puts you at high risk for respiratory depression. So we did not want to go to a higher dose. In the pediatric surgery, they had two to four micrograms. We wanted to bring it down.

So, an hour after the surgery they can start eating, which is not true for the PCA because they are nauseous — they cannot eat for almost a day or two. My kids can start eating an hour later. That means they can swallow pills. So I don't have to give them injectable morphine. And we depend a lot on Tylenol and Advil, alongside, of course, we do have about three to five days some oxycodone, but mostly not much of injectable.

Sandra Lindsay: 14:30
Compared to patients receiving PCA, those benefiting from the Rapid Recovery Protocol received nearly one-tenth the amount of morphine, and were prescribed half the amount of oxycodone post-surgery, according to a 2021 paper Dr. Sarwahi published in the Journal Spine.

Even refill requests decreased.

Dr. Sarwahi: 14:52
One night in the ICU, 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 in three to five days of some oral pain medications.

Sandra Lindsay: 15:03
The microdose does require surgeons to not only think differently about pain management, but to thoroughly prepare their patients on what to expect.

Dr. Sarwahi: 15:14
I always educate my patients. I tell them, hey, expect the pain to be around three to four on a scale of zero to ten. A lot of time when you prepare them, they are, kids are smart. They understand, they listen, and their expectations are accordingly fine-tuned essentially. We almost decreased the opioid consumption by 80%. And I'm very proud of it. It's a very, it's a big, big thing. 80% less opioids. And better pain control.

The journey still continues. This is not the end of Duramorph. We are now looking at if there is a difference, and actually there is, if the Duramorph is given before surgery by the anesthesiologist, before they go into anesthesia or before even I make an incision, versus if I give it at the end of the surgery. That three-hour difference makes a huge difference in the amount of opioids. If they get injection before the surgery, the nervous system is already primed, so they wake up much better, requiring less pain medication.

Sandra Lindsay: 16:20
Since publishing these findings in 2021, Dr. Sarwahi says he and his team continue to update this technique and explore new ways to improve the surgery.

Dr. Sarwahi: 16:31
Technology has evolved. Our technique has evolved. In a classic scoliosis surgery, we open your back, you move your muscles away, we have to expose the entire bone essentially. And then we reattach it. But moving muscles, if anybody who has had a sprain of the ankle or the knee, and a major sprain, will attest to that it's a very painful thing. Now Imagine your whole back has been sprained.

But the same surgery, I've been doing it in a less invasive manner. I don't strip your muscles the same way. I'm preserving your muscles. I find the natural plane that exists between those muscles. Imagine if I keep my fingers next to each other, just separating those fingers out instead of chopping those fingers out. I just separate those. Your muscles are still attached.

I find the 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 published a few years ago, we found almost 99% of them did not need a blood transfusion, which is compared to 20%, 30% patients require blood transfusion is a major win. The downside is it does take a little bit longer, but with experience, this should decrease also.

Sandra Lindsay: 17:51
This minimally invasive approach started taking shape 10 years ago and also takes into account the scars left by surgery.

Dr. Sarwahi: 18:01
Depending on the type of the curve, you can have two curves, or it can be your whole back. But instead of now one long incision in the back, I'm getting away with three non-contiguous, so they're not connecting to each other, incisions. So, if you have a swimsuit on, probably you will not notice a long incision. You'll just notice a tinier incision. But it's not about the incision, right? It is more about pain and long-term benefits of it. So we realized that this approach has been in place for quite some time, and we just combined two plus two together and we came to this.

Sandra Lindsay: 18:39
The latest evolution to Dr. Sarwahi’s approach aims to improve accuracy when placing screws during scoliosis surgery. And he’s doing it using a combination of technique and technology — or TNT for short.

Dr. Sarwahi: 18:56
I've put almost 70,000 screws now, and you always worry that what is happening if by chance the screws are misplaced.

So think of it like navigation, your car navigation, right? I mean, you go home every day, you drive every day, you know the roads, but still you switch on your Google Maps because it may tell you the faster way of reaching there.

Sandra Lindsay: 20:42
The problem with that, he told us, was you still didn’t know if your screws were placed accurately because scans were taken before placing the screws around the spine, not after.

Dr. Sarwahi: 20:53
You're presuming that your screws have been placed accurately.

Sandra Lindsay: 20:57
He acquired an intraoperative CT scan machine called Aero and began taking scans during and after to confirm the placement of screws was accurate. But he found another downside.

Dr. Sarwahi: 21:11
When we started adapting this technology, my two-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 means more anesthesia for the patient, more chance of blood loss, more chance of infection. Why would I want that? And more pain. Why would I want that?

So, we came up with this thing called TNT, which is a short for technique and technology. I know that I have the surgical technique of putting screws. I've been doing it all these years. I'm pretty facile with it. And as I start putting screws, there will be one or two areas which will be challenging. I can skip those.

And I continue putting the remainder of the screws. And once I'm done, I bring in my CAT scan. It takes two 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've skipped, I can now use navigation. And pretty soon, I've been able to put it back to two-and-a-half hours and with better accuracy now. So that approach, we call it TNT. It is as if we are combining all these things together and not only making surgery safer but also more efficient and outcomes better.

Sandra Lindsay: 22:23
Dr. Sarwahi is now studying the effectiveness of his TNT approach.

Dr. Sarwahi: 22:28
We are the only place in the country which is doing it… This technique gives me best of both worlds.

Sandra Lindsay: 22:34
As we wrapped up our conversation, Dr. Sarwahi said parents and patients are thrilled to hear that opioids are not so heavily relied on.

Dr. Sarwahi: 22:44
Parents are asking for it. Kids have become smarter. They are on board with this. But parents are demanding it equally.

Sandra Lindsay: 22:53
While many continue to use PCA and prescribe opioids for surgical pain, he said he sees a positive trend of surgeons looking for ways to reduce their reliance on the dangerous painkillers.