5 Observations on Spine Surgery Heading to Outpatient Procedures

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Dr. Santi Rao on spine surgeryHere are five thoughts on spine surgery's migration into the outpatient setting and where spine procedures are headed in the future.


1. Outpatient spine surgery has been proven effective, and is growing.
There have been several advances within the spine systems and surgical technology to perform minimally invasive spine surgery; equally as important are the advancements in anesthesia, pain and infection control in allowing spine surgeons to move their cases into the outpatient setting.

"The transition into the outpatient setting was made possible by cameras, microscopes and other visualization techniques so we could see things clearly, as well as anesthesia for these patients," says Santi Rao, MD, an orthopedic spine surgeon of California Spine Care in Conford, which performs outpatient surgery at San Ramon Surgery Center. "The patient benefits with outpatient spine surgery because there is less recovery time and less collateral damage from the minimally invasive spine procedure."

Patients who undergo minimal access spine surgery have less blood loss. Postoperative pain management has developed so that patients can return home the same day as surgery.

"We have to give credit to development in anesthetic techniques, which have improved considerably over the past 15 years," says Dr. Rao. "Patients are now able to wake up and go home earlier without any side effects. They wake up after surgery as if nothing had happened and they feel much better."

In the future, surgeons may be encouraged to make the change because surgery centers are more economically viable for insurance companies. "It costs a fraction of the price to perform a case outpatient instead of in an inpatient facility," says Dr. Hieu Ball, MD, an adult and pediatric spine surgeon with California Comprehensive Spine Institute in Walnut Creek. "The cost savings is staggering for insurance companies, but in many cases the insurance companies are not encouraging or recognizing that value."

2. Revolutionary instrumentation will continue to evolve.
There are several platforms for minimally invasive spine surgery seeking to revolutionize the field. These new techniques focus on motion preservation — either through biological repair or artificial discs. With further development, these techniques could replace the traditional spinal fusions for many patients in the future.

"We've had advances in artificial disc replacements and now more companies are coming forward with artificial discs, especially in the neck," says Dr. Rao. "It's less difficult to receive authorizations and reimbursement for artificial disc replacements now than it used to be. We also have many different types of bone graft products which are more profitable and effective for obtaining fusion than before."

In the future, Dr. Rao sees surgical technique advancing to the point where surgeons can insert an artificial disc through a lateral approach. Surgeons are currently able to perform lateral lumbar interbody fusions, which have been proven successful for the appropriate patients.

"There is also work being done in nucleus replacement into the center of the disc," says Dr. Rao. "It will be quite a few years before we have that technology fully developed, but these are exciting things coming down the pipe."

3. Younger surgeons are training on minimally invasive techniques.
Even though minimally invasive spine surgery has shown clear advantages for patients in the short term, it was slow to spread across the United States because most techniques have a steep learning curve; it didn't make sense for surgeons to leave their practices and train for months on new procedures when their patients had good outcomes with standard open surgery.

"It's a technique that older surgeons don't want to have to relearn, like artificial disc replacement," says Dr. Ball. "There are some surgeons who can do it, but surgeons who have been in practice for 30 years will likely continue doing what they always did. There has to be a real comprehension of the 3D anatomy to use the new technology and some surgeons are better at it than others."

However, now more surgeons are training on minimally invasive technique during fellowships and incorporating it into their practice.

"One of the problems has been the steep learning cure with surgeons, and surgeons who are already in practice face a dilemma of whether they should switch and how rapidly the change should take place," says Dr. Rao. "Fortunately, younger surgeons are training on these procedures. Over a generation we should see a major change in how about how our routine spine procedures are handled."

However, even spine surgeons who learn minimally invasive techniques during training will face new instrumentation and developments going forward. Learning new techniques takes time and energy, and often slows the operating room until everyone is familiar and comfortable with the procedure. Make sure any procedure you learn is worth the investment before taking the plunge.

"If a spine surgeon is interested in a particular technique, it's important to identify nationally what companies are doing and what the surgeon wants to do personally before just jumping in," says Dr. Rao. "Evaluate the technology and verify it will do what it says will do. Find associated technology and once you've narrowed down the field go and visit a surgeon who already uses the technique. Get a feel for what works best in your hands. Figure out whether you can use the technology on other techniques because if it's a dead end technique, it won't help you with other surgeries. It should be versatile and expand your skill set into other areas."

4. Change will occur to make spine surgery more economically viable.
An intense focus on the cost of care has become ubiquitous in the healthcare system, and spine surgeons will be incentivized to do their part in lowering the cost of care. This may mean using lower priced implants where possible and performing cases in the outpatient surgical center — which is reimbursed less than the hospital — using less invasive techniques.

"The new technology shifts a lot of surgeries out of the hospital into surgery centers," says Dr. Rao. "Patients have short or no hospital stays, which has a huge economic impact on the healthcare system. The patients and community also benefits because patients are able to return to work more quickly and don't have to lose their jobs."

Outpatient procedures mean patients will be mobilized and moving less than 24 hours after surgery. Quicker movement and rehabilitation means a speedier recovery and patients are often looking to return to work as soon as possible.

"When surgeons perform minimally invasive procedures, we see the results in return to work time and less disability," says Dr. Rao. "I think these are driven by the economy where people can't afford to take time off."

However, in some marketplaces it may be difficult to make the transition. "It depends a lot on the local community," says Dr. Ball. "For some, bringing spine to ASCs is outside of community standards; they are concerned that something will go wrong. There are huge economic incentives for insurance companies to allow ASCs to perform spine procedures, but surgeons hesitate if everyone in the area is opposed to outpatient spine. Surgeons in that situation may not want to take the risk and put their neck out there as an outlier in the community."

5. Partnerships with pain management and conservative care providers are become essential.
Integrating care is another facet of healthcare reform and more spine surgeons are reaching out to non-operative specialists as they seek to expand their practice. These specialists could include interventional pain management, physical therapy, physiatry, physical medicine and chiropractic care, depending on what the patient needs most.

"Spine surgeons in the future will need to stop thinking of themselves as surgical technicians because the patients coming to see them aren't there for spine surgery; they are there because of back pain," says Dr. Rao. "When surgeons start to think of themselves as doctors rather than surgical technicians, they will incorporate care of these patients' psyches, non-operative care and other solutions into their practice. The patient's treatment pathway should go through the surgeon because the surgeon is in the best position to comprehend the anatomy, the structures involved and the relationship to the pain, functional impairment and the patient's overall suffering."

Current reports show that a majority of people will suffer from acute or chronic back pain at some point in their lives and 90 percent of spinal problems don't require surgery. Some surgeons in the future may choose to become experts at injections and pain management to become more comprehensive in their treatment options for patients.

"As surgeons incorporate the benefits of maximal care, non-operative techniques, injection, medication usage and minimally invasive techniques into the care of their patients, they will become more centrally positioned to provide spinal care with the authority that such comprehensive knowledge commands," says Dr. Rao.

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