The state of outpatient spine: 5 surgeons' thoughts

Spine procedures like total joint replacements are increasingly moving to the outpatient setting, with ASCs on the forefront of the transition.

Here are five surgeons' thoughts on outpatient migration:

Jason Weisstein, MD. Cleveland Clinic (Stuart, Fla.): With the rapid pace of today's technological advances, joint replacement will see the introduction of smart implants that will be able to monitor the cellular environment for infection or early signs of loosening. Joint replacement will also continue to evolve with improved pain control and increased utilization of outpatient-centered surgery protocols.

Anthony Melillo, MD. Bay Oaks Orthopaedics & Sports Medicine (Houston): I see joint replacement surgery continuing the upward trajectory. This is due to several factors, including childhood and young adult obesity, increased longevity and greater demand for active senior lifestyle. More and more of these procedures will be performed as an outpatient or 'observation' status so that payers can justify lower reimbursements, even though it takes good clinical judgment and advanced surgical skills to improve outcomes and patients' satisfaction.

Ciro Randazzo, MD. IGEA Brain, Spine & Orthopedics (Union, N.J.): There's also significant hospital pressures that continue to mount, including a need to justify any implants that we're placing and their cost-effectiveness and relationship to positive outcomes. I feel there's significant pressure from hospitals to continue to do surgeries in the hospital setting. But there is more and more data that shows we should continue to migrate our cases to outpatient facilities, such as surgical centers, when that is possible. I think we have to look for new and interesting ways to bring more cases to surgical centers. 

Wesley Bronson, MD. Mount Sinai Health System (New York City): Ample research has demonstrated the safety of performing outpatient spine surgery in ASCs, especially for common procedures such as microdiscectomy, laminectomy, [anterior cervical discectomy and fusion] or cervical disc replacement, and even some more complex cervical and lumbar fusion procedures. Through a combination of careful patient selection, preoperative planning and perioperative techniques, complications are low, and the need for transfer to a formal hospital is low. Nonetheless, many surgeons are reluctant to transition these patients into ASCs due to the potential for complications that may be difficult to manage in an ASC, such as hematoma, airway compromise, [cerebrospinal fluid] leak or intractable pain. I believe as more research is published demonstrating the safety profile of these procedures in the ASC setting, more surgeons will feel comfortable transitioning more procedures out of the hospital setting.

Niranjan Kavadi, MD. Spine Surgeon in Oklahoma City: The most important trend at this time in healthcare saving orthopedics is the transition to outpatient surgical care whenever feasible. Traditionally, open musculoskeletal procedures have been associated with postoperative pain interfering with rehabilitation. Minimally invasive techniques to achieve excellent outcomes are evolving rapidly, with an advantage of less surgical morbidity and quicker rehabilitation. Specifically for the spine, endoscopic techniques are appealing. Obviously, careful selection of patients who are suitable for outpatient care is essential. Outpatient surgery not only can potentially save the hospital setting resources for sicker patients but also has a positive psychological impact on the patients, facilitating rehab and return to daily activities.     

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