Seven spine surgeons discuss outpatient spine surgery and where it's headed in the future.
Q: What are the most important innovations in outpatient spine today?
Neel Anand, Clinical Professor of Orthopedic Surgery and Director of Spine Trauma, Cedars Sinai Spine Center, Los Angeles: Minimally invasive spine surgery is one of the most important innovation in outpatient spine today. New techniques have really changed what we can do in surgery especially with techniques that enable less blood loss and dissection through less invasive procedures. This makes it overall easier to perform spinal surgery in the outpatient setting.
Todd Alamin, MD, Stanford Medicine, Redwood City, Calif.: Better operative microscopes that allow for surgical goals to be accomplished through less disruptive exposures [with] better lighting, visualization, magnification. Newer, longer acting local anesthetics promise better pain control for the early postoperative period, like liposhpere-encapsulated bupivacaine.
Neil Badlani, MD, North American Spine, Houston: Tubular retractor systems with specialized instruments and high powered microscopes or endoscopes allow procedures to be done in this fashion. Better instrumentation including more percutaneous instrumentation and stand alone interbody cages are important advancements. Alternative approaches to the spine such as the lateral approach or mini-open anterior or oblique approaches allow access to the spine without significant disruption of muscle.
Perhaps more importantly, as surgeons we are doing a better job of utilizing all of these tools and understanding the many factors necessary to do these procedures in a less invasive fashion. Patient education is critical to establish and manage a patient's expectations about recovery after surgery. We are also working more with our anesthesia colleagues to utilize multimodal pain control methods to allow spine surgery to be done safely in the outpatient setting.
Sanjeev J. Suratwala, MD, Orthopedic Spine Surgeon, North Shore-LIJ Health System, Assistant Professor, Department of Orthopaedic Surgery, Hofstra NS LIJ School of Medicine: The way we approach managing pain and disability after surgery has seen some innovations. When you are trying to perform any type of surgical procedure and make it outpatient instead of inpatient, you want to focus on minimizing the patient's pain.
There are new percutaneous surgical techniques, minimally invasive surgical techniques as well as robotic technology and new devices that require smaller incisions so patients don't have as much pain or disability. The recently popularized lateral approach to spine surgery also minimizes dissection and tissue damage for interbody fusions.
From an even bigger picture standpoint, we are looking at whether we need to perform traditional spine surgery at all in the first place. Instead of performing laminectomies we can consider implants like the coflex device that decompress while minimizing morbidity. Traditional spinal fusions could be replaced with motion preserving techniques.
Q: What new technologies or devices could make an impact on outpatient spine in the future?
NB: Spine surgery is still a frontier with constantly advancing technology. Robotic spine surgery will likely continue to become more common and make a bigger impact on less invasive spine surgery. We can expect continued advancements in instrumentation and spinal devices. New technologies that help minimize blood less during spine surgery such as the use of tranexamic acid or transcollation technology will make an impact.
Stephen Hochschuler, MD, Co-Founder, Texas Back Institute, Plano: Everyone is looking to decrease costs for spine procedures, and ASCs receive lower reimbursement than hospital outpatient procedures. With image intensification such as the O-arm and robotics, people are comfortable doing quality outpatient procedures because they are going to be more percutaneous. The portable CT scan makes this a different world. Surgeons are getting used to it and it's becoming the paradigm of care.
SS: The interspinous devices such as X-stop and now coflex are being researched and looked at to minimize the traditional laminectomy approach. The disc replacement implants especially in the cervical spine are approved in the United States and are seeing increased usage. That's something that can be done as an outpatient procedure because you are minimizing restrictions afterward.
The goal here is to keep patients mobile. The early research on disc regeneration technology is promising. If we can regenerate the disc then we don't have to perform a fusion or disc replacement. That could change procedures tremendously and likely remain in the outpatient setting.
Robotic surgery has also made it technically possible to do more challenging cases with less invasive procedures. When you minimize the incision and the muscle trauma, you can significantly reduce post-procedure pain and disability which is often the primary reason for prolonged hospitalizations. The targeted robotic approaches are one way to convert the traditional inpatient procedures to outpatient surgeries.
TA: Less disruptive fusion techniques and better methods and techniques for endoscopic decompression. Current options probably are too difficult for broad use and further have structural issues associated with them.
Q: There are still people who are skeptical of doing any spine procedures in the outpatient setting. Will anything change their minds?
Gowriharan Thaiyananthan, MD, Neurosurgeon, Founder, BASIC Spine, Newport Beach, Calif.: The key is to provide skeptics with information and data. Surgical procedures done in the outpatient surgical setting are producing better results both for the patient. The infection rates are lower, post operative complications rates are lower (because the procedures that are performed are less risky), and patient satisfaction is higher. Also, overall costs are much lower. Providing patients with the same information that we use practice evidence based medicine may help people who are skeptical of outpatient spine procedures see the paradigm shift which is occurring.
Q: How can spine surgeons optimize their outpatient procedures?
NB: Patient education and patient selection is the most important aspect of this. Patient's should be willing and motivated to have an outpatient procedure and interested in a quicker recovery. When transitioning surgery from the inpatient to the outpatient setting, it is prudent to have a stepwise approach and start with more straightforward procedures in healthier patients first and expand indications later. It is safe to have the option to admit to an inpatient facility if necessary particularly early on in the process.
NA: Surgeons must make sure they have a really good anesthesiologist. Make sure all the equipment is where it should be and you have everything you need at the outpatient center. If something were to go wrong, you also need a plan. If the patient loses more blood than expected, you have to be able to take care of that patient.
Bonaventure Ngu, MD, Premier Spine Institute, The Woodlands, Texas: It's important to make sure the patients' pain is controlled. We're making the switch from using IVs to oral narcotics. Now with the less invasive procedures, the patients require less narcotics than they did before. They're also in pain for fewer days.
Q: What do spine surgeons need to know about transitioning cases from inpatient to outpatient?
SH: Start taking the healthy patients to the outpatient surgery center and then take older patients there as you feel more comfortable, if they're a good fit for outpatient surgery. Begin with injections — nobody needs the hospital for injections. Then expand to laminectomies and discectomies. Whether they are percutaneous or open, that's a fail-safe procedure. Then go to fusions but make sure you have a good vascular surgeon with you if they are anterior fusions.
BN: The most important aspect to emphasize is medical preparation. Patients think they are coming in for surgery and then they'll stay at the hospital for two or three days before going home. But if the patient's surgery is in the ASC, they have to leave earlier and you want to make sure they're ready for that. Make sure they're ready to experience some pain after they go home.
SS: It's very important to have a good team approach when performing complex surgeries as an outpatient. Good outcomes start with good patient education. When a patient comes into your office, the assumption is he or she will be hospitalized for a few days after their spinal surgery. It takes some effort to convince the patient that the surgery can be done in an ambulatory setting. Patients and staff should be on the same page and know they're undergoing outpatient surgery. The education of your staff is also critical here so that there are no mixed messages. The clinical team should emphasize adequate pain management and early ambulation.
Then I begin to think about patient selection. Book patients conservatively for the outpatient ASC when first transitioning cases. There is a learning curve to get everyone transitioned, but it's certainly feasible for discectomies, decompressions performed with implants, and anterior cervical spine surgeries. Percutaneous fusions can be challenging to perform in an ambulatory setting but with the right patient and the right team can be performed.
TA: Plan for problems that may occur. Collect emergency contact numbers for patients and plans for transfer to the in-hospital setting if necessary. Sometimes the outpatient plan does not work. You need a plan in place to deal with that upfront so that "bounce backs" don't happen. That's a big patient dissatisfier and quality control problem.
The most frequent problem is postoperative urinary retention in older men. Have a plan for minimizing this potentially with input from the patient's urologist.
Q: Where do you see the biggest opportunities in outpatient spine in the future?
SS: With the reimbursement declining and expectations that surgery should cost less, there is more pressure on healthcare providers and facilities to get patients home sooner. I think the push from the financial standpoint will drive innovation and change. People are critically looking at whether a person needs a certain procedure like spinal fusion because there are alternatives.
Costs and finances matter in the transition to outpatient procedures. In this economy, a lot of spinal care is being driven toward ASCs because their core function is getting patients home sooner. But one caveat is this trend shouldn't compromise patient safety. Just because you can save on costs for outpatient procedures doesn't mean every case should go there. Make sure you're treating the patient appropriately for their condition.
SH: ASCs are one of the few opportunities surgeons still have to invest, and when surgeons own part of the facility they demand it run better. At our specialty hospital, which we still have ownership in, we run outcomes tests and ask how patients felt about their stay. The ownership also gives physicians an ancillary source of income.
GT: New technologies that could impact outpatient spine surgery in the future include the development of cost effective implants that can be used in the ASC and surgical technology that allows traditionally inpatient procedures to be done in an outpatient setting. Two main factors in technology development that facilitate this are less invasive procedures and shorter surgical time. One example is interspinous spacer or clamp as an alternative to pedicle screw fusion.
Q: Will more spine surgeons be performing cases in outpatient ambulatory surgery centers?
NB: Absolutely the trend toward outpatient spine surgery and minimally invasive spine surgery will continue to grow. More surgeons are continuing to adopt and expand these techniques. There is a great benefit to our patients because of less pain, less blood loss and faster recovery. Also, with the continued emphasis on controlling health care expenditures, it is important to transition procedures to the outpatient setting.
GT: There's definitely a shift towards outpatient spine procedures already occurring. As the costs of implants continue to decline and as the technology for truly minimally invasive spine surgery improves, I believe more spine surgeons will be performing cases in an ASC environment. Additionally, as the emphasis from patients and insurers grows to perform procedures in an ASC, more spine surgeons will probably begin a paradigm shift of performing cases on an outpatient setting.