Dr. Khoi Than: Evolving patient populations, AI and the future of outpatient procedures in spine

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Khoi Than, MD, is fellowship-trained neurosurgeon joining Duke Spine Center in Durham, N.C. 

Dr. Than is transferring his practice, leaving his role as assistant professor of neurological surgery at Oregon Health and Science University School of Medicine in Portland. 

He completed fellowship training in minimally invasive and complex spine surgery at University of California San Francisco before joining OHSU in 2015. His new practice at Duke will focus on minimally invasive and robotic surgery.

Here, Dr. Than discusses artificial intelligence, changing patient populations and the future of outpatient procedures in spine.

Question: How do you see artificial intelligence impacting spine surgery?

Dr. Khoi Than: We are seeing some great work being done in the realm of AI and spine surgery. I think AI has immense promise as an adjunct to surgical decision making. In other words, for cases where the best surgical plan is not clear, a surgeon could use AI to develop one based on a patient's chief complaint, demographics, co-morbidities, physical examination, and imaging findings. While the applications of AI are nearly endless, this is one I'm particularly excited about.

Q: How has your patient population changed over the past five years? How do you expect it to evolve in the future?

KT: I spent the past four years at Oregon Health & Science University, where I developed a strong referral network of patients who had undergone previous spine surgery elsewhere but did not heal appropriately or still had residual symptoms. During my time there I saw more and more of those types of cases, and fewer primary or virgin cases. Patients would come not only from Oregon but also Washington, Idaho, California, Montana, Alaska and Pennsylvania. The furthest patient I saw and operated on came from the United Arab Emirates. 

I'm about to join the fantastic spine program at Duke University in Durham, N.C., where I know patients will come from all over the region, nation and world. My focus at Duke will be on patients with spinal pathologies that can be treated minimally invasively, which these days includes basically all spinal pathologies except for the most severe deformities.

Q: How can surgery centers improve profits without increasing patient costs or sacrificing quality?

KT: Advocacy is the best way for surgery centers and those who work there to accomplish these missions. Payers have many strange policies. For example, a Medicare patient with a lumbar synovial cyst will not have their surgery covered unless the patient is admitted overnight. Similarly, the reimbursement for a patient who undergoes an outpatient anterior cervical discectomy and fusion is substantially lower than if the patient is admitted to the hospital. How does any of this make any sense? Fortunately, groups such as the American Association of Neurological Surgeons and Congress of Neurological Surgeons' joint spine section are advocating on behalf of surgeons to rectify issues like these.

Q: How do you see outpatient spine procedures developing in the future?

KT: Surgeons will continue to push the limits on what can be done in the outpatient setting. When I started my training a dozen years ago, all anterior cervical discectomy and fusions were admitted for at least a night. Now, most are done outpatient. We are seeing some do awake fusion procedures which allow for quicker recovery and discharge. Smaller incisions, better technology, and improved perioperative pain control will continue to allow patients with bigger surgeries to be done as outpatient procedures. 

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