Aware State Diagnosis


Aware State surgery is routinely practised at the Spinal Foundation for a number of reasons:

  • Increased safety for patient and surgeon.
  • Less risk of nerve damage.
  • More selective and minimal intervention.
  • Greater accuracy in diagnosis.
  • More precise treatment of the pain source.
  • Day case surgery.
  • Useful for elderly or infirm patients.
  • Expands the envelope of disabilities that can be treated.

Aware State Diagnosis

Aware State Surgery is performed under a continuous intravenous flow of painkillers 100 times stronger than morphine. This allows the patient to communicate with the surgeon throughout the procedure with realistic clarity. In turn this allows the patient to help the surgeon to more accurately identify the source of the pain, assess the status of adjacent disc levels and identify the nerves and so protect them during the procedure.

The feed back gained has allowed us to determine the sources and mechanisms of pain directly from the patient. This has confounded existing thinking and allowed us to develop Minimally Invasive Spine Surgery to treat these sources more specifically and effectively.

Aware State surgery avoids the use of General Anaesthesia. General Anaesthesia renders the patient inert and unresponsive and the surgical procedure performed must therefore rely upon preconceived preoperative conceptions of diagnosis with error rates of 20 - 26% in cases of non-compressive radiculopathy or Failed Fusion Surgery (Knight MD Thesis University of Manchester 2003 and Knight et al SPINE 2002).

Avoidance of General Anaesthesia, avoids the considerable disturbance to the heart, kidneys and the lungs caused by the vascular changes caused by general anaesthetic agents so allowing the technique to be performed in the elderly and infirm.

Aware State Treatment

Muscle Balance Physiotherapy

At the Spinal Foundation we seek to avoid surgery by the implementations of muscle balance physiotherapy with the correction of posture, load transposition and intersegmental movements. But where this fails then either continued conservative therapy in the form of injections and physiotherapy may be continued or surgery considered.

Lumbar Interventions

The theatre teams, technicians and anaesthetists are specifically trained for operating with their patients in the "Aware State" and are extremely considerate of the anxiety caused by this type of surgery. The patient is usually prepared with a pre-med but remains aware for the duration of the operation but often drifting off to sleep for periods. The anaesthetist sedates the patient without allowing loss of consciousness so that the patient is able to respond to questions posed by the surgeon as the procedure progresses. This information is essential to the surgeon as it enables him to remove only symptomatic material, whilst leaving as much healthy tissue behind and so retain as much functional disc as possible. Importantly patient led guidance allows the surgeon to explore the foramen and remove scarring and tethering of the nerve, correct medial displacement of the nerve and remove impingement upon the nerve caused by bone spurs and ligaments.

The Anaesthetist controls the rate of sedation throughout the course of the operation according to the pain level reported by the patient. Often, once the initial investigative stage is complete, the patient feels little more than discomfort and the tapping sensation of the laser or radiofrequency devices or the whirring of powered instruments. Occasionally the heat from the laser becomes uncomfortable and the surgeon, not wishing to cause damage, will stop until the heat abates and avoid this area from further lasing until the area is mobilised. Manual mobilising of the nerve can cause discomfort but the surgeon will warn the patient before this essential step is undertaken. The pain caused is short-lived but often causes immediate improvement in the presenting symptoms.

At the end of the procedure the patient will perform the "Push up" test and the "Leg Extension" test to check that sufficient decompression and nerve root mobilisation has been performed.

Cervical Interventions

The technique is performed in the supine position for cervical surgery with the same anaesthetic and analgesic protection. Probing is applied to the anterior annulus and followed by discography. The patients responses at each and every stage are recorded and analysed for concordancy (reproduction of patient's presenting symptoms
Once the index level has been determined, then a laser probe or endoscope and laser probe is railroaded to the disc and the degenerate disc material and osteophytes are removed.