Spine surgery is moving outpatient quickly, but the hospital is not disappearing from the equation.
Lumbar fusions, cervical disc replacements and endoscopic procedures that once routinely required hospitalization are increasingly being performed in ASCs. The harder question now is where do surgeons draw the line between patients who can be treated at an ASC and patients and procedures still needing hospital-level resources.
Recent Becker’s reporting suggests that line is being determined less by the procedure name alone and more by patient health, surgical complexity, expected blood loss, postoperative monitoring and whether the ASC has the infrastructure to manage complications.
The sickest patients still belong in the hospital
Patient selection remains the clearest dividing line.
Michael Burdi, MD, of DISC Newport Beach in California, performs some multilevel posterior lumbar fusions in an ASC, but said the setting is not appropriate for everyone.
“If somebody is critically ill, you probably won’t do that case at the surgery center,” Dr. Burdi told Becker’s.
Age itself is not necessarily disqualifying. Dr. Burdi has performed a two-level fusion on an 84-year-old patient, but called that an exception and said older patients require closer evaluation of comorbidities and bone quality.
“With older patients, you have to consider comorbidities that might indicate that a case is better for the hospital,” he said.
Complexity is no longer defined by level count alone
A three-level fusion does not automatically require hospitalization anymore. Dr. Burdi said healthier patients can undergo straightforward three-level fusions at highly specialized ASCs, although those procedures represent only about 5% of his ASC case mix. More complicated three-level cases remain less common in the outpatient setting.
That reflects a broader shift in spine care: complexity increasingly depends on the patient, procedure and facility together.
Steven Crider, MD, of Watkinsville, Ga.-based Origins Spine and Joint Physicians, warned that outpatient expansion could move faster than appropriate patient selection.
“I think you’re probably going to have a lot of providers that are doing inappropriate cases in the ASC,” he said, referring to patients who are too medically complex for the setting.
Predictability matters as much as surgical capability
A surgeon may technically be able to perform a procedure outpatient, but that does not mean the surrounding system is ready for it.
Kern Singh, MD, professor and chief of spine surgery at Chicago-based Rush University Medical Center, told Becker’s that predictable anesthesia is one of the foundational requirements for outpatient spine surgery.
Pain, bleeding and other postoperative issues can compound and “prevent a patient from being safely discharged,” he said. That makes the threshold for ASC surgery different from the hospital. A complication that can be monitored overnight on an inpatient floor may become a reason not to perform the case in an ASC at all.
Dr. Singh also said certain expensive technologies may make more sense for complex cases requiring hospital resources than for routine outpatient procedures.
The ASC itself can be the limiting factor
Not every surgery center that wants spine volume is equipped for complex spine surgery. Nikhil Shetty, MD, COO of Munster, Ind.-based Midwest Interventional Spine Specialists, told Becker’s that ASC leaders can get into trouble when they add service lines their staffs are not equipped to support.
“What is even more important than that is to know what you’re good at,” Dr. Shetty said.
For more complex outpatient spine procedures, that can mean specialized nursing, anesthesia, imaging, microscopes, instrumentation, recovery protocols and a reliable plan if a patient requires escalation of care.
Hospitals may increasingly inherit spine’s hardest cases
The migration of routine procedures also changes what remains behind.
Aqib Zehri, MD, a neurosurgeon at The Oregon Clinic in Portland, told Becker’s hospitals are already seeing more complicated patients as straightforward procedures move outpatient.
That could leave hospitals with a growing concentration of patients who are older, medically fragile or undergoing revision and other high-acuity procedures, exactly the cases most dependent on multidisciplinary support, extended monitoring and rapid access to additional services.
The shift therefore does not necessarily make the hospital less important to spine surgery. It may make its role more specialized around the patients ASCs are least equipped to manage.
The line will keep moving
Recent Becker’s reporting suggests the boundary between hospital and ASC surgery will continue to move.
Techniques are becoming less invasive, anesthesia and pain-control protocols are improving and specialized ASCs are taking on procedures once considered too complex for outpatient care. Dr. Burdi is already performing selected three-level fusions in that setting, while ASC leaders say lumbar fusion, cervical disc replacement and endoscopic surgery are increasingly part of outpatient programs.
But moving more care outpatient does not mean moving every case.
As Dr. Zehri put it, the future is about delivering “the right surgery for the right patient in the right setting.”
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
