One of the first three-level lumbar spinal fusions at an ASC was recently performed by Jeffrey Carlson, MD, president of Orthopaedic & Spine Center in Newport News, Va.
Dr. Carlson spoke with Becker's Spine Review about what minimally invasive spine surgery means to him and offered advice for surgeons migrating higher acuity cases to the outpatient setting.
Note: Responses are lightly edited for style and clarity.
Question: How has outpatient spine surgery developed to the point where you can perform a three-level lumbar fusion at an ASC?
Dr. Jeffrey Carlson: This has been a process over the last 10 years, developing surgical methods that are less traumatic to the patient, with the idea that you're going to decrease the pain related to that surgery. A lot of people will define "minimally invasive surgery" as smaller incisions. In my mind, the goal of minimally invasive surgery is to decrease pain, which is done by decreasing the trauma of the surgery itself. Surgeons should be focused on decreasing the surgical trauma to the patient and fix the real problem, the nerve compression and/or any spinal instability. If I can fix the patient's spine through a small incision, with the same visualization and less trauma to the patient, then I would consider that a "minimally invasive surgery."
Over the years, we've developed techniques to be able to use a standard midline approach, but with a smaller incision than the standard open incision. Spine surgeons have been taught this approach as the mainstay of spinal surgery. A midline approach can allow us to do our neurogenic decompression and also place screws through the same incision. As you get more facile at this, you can make the incision smaller and see what you need to without disrupting as much tissue. So, you're able to actually visualize the nerve roots, the bone, the discs and place cages or screws all through the same incision. Over the years, we've gone from single-level to two-level and now three-level all, through a small incision. The pandemic certainly pushed us more toward outpatient surgery so as not to overburden hospitals. Now we are doing major spine procedures like this one on an outpatient basis. That has been a real silver lining.
Q: What advice do you have for other spine surgeons considering performing higher acuity cases like a three-level lumbar fusion at a surgery center?
JC: The biggest thing is patient selection. Making sure you've got the right patients for the outpatient setting, especially when you're starting. Patients with significant medical issues may not be right for an outpatient surgery. Also, your goals must align with the patient's. You've got to have the family on board with the patient recovering at home after surgery, rather than the family expecting the patient to stay overnight at the hospital. That conversation starts in the office when we talk about what the surgical options are, going over the risk-benefits of each particular option and helping the patient visualize what outpatient surgery looks like versus inpatient surgery.
Make sure they understand what the steps are and what to expect right after surgery, so they're not going to the emergency room with issues that are expected after surgery. The outpatient surgery center is geared toward getting patients home, so we really encourage patients to get up and get ambulating, as well as understanding what their pain is supposed to be after surgery. Problems urinating, nausea, vomiting and fever make it more difficult for patients to be at home. You need to really help your staff, especially anesthesia and nursing, to develop their skills for an outpatient center. Expectations around hospital-based surgery are different than at the outpatient surgery center.
Q: What does a natural progression look like for surgeons moving toward adding multilevel spinal fusions to the surgery center?
JC: If you're able to do the smaller surgeries — microdiscectomies or smaller cervical or lumbar decompression — then you can look at trying to add other surgeries. If you can do a lumbar discectomy at the surgery center, then the next steps would be adding laminectomies, then fusions, then interbody fusions. Continue to add to your skill and technique without harming surrounding tissues or increasing the pain related to the procedure itself. If you can do a microdiscectomy or a laminectomy through a one-inch incision, you may be surprised to see that you can put in screws through the same incision. And if you can do that, you're on your way to making an inch and a half incision to be able to do a two-level or three-level spinal fusion.
Q: Are there any spine surgeries that you're considering adding at your surgery center?
JC: We do pretty much everything at our surgery center. The only procedures that we're not doing are some of the long scoliosis surgeries and posterior cervical spinal fusions. The bigger procedures that have more risk of complications, you may want to have them done in the hospital, as there is the potential need for an ICU. From a patient standpoint, there are those patients that have other medical issues or comorbidities that put them in a position where it may not be safe to have them at home after a lumbar fusion or cervical spinal fusion. Those patients would need to have their surgeries at the hospital, where more staff are around to watch them closely.
Q: How do you expect hospitals to compete with surgery centers as spine and orthopedic procedures continue to migrate to the outpatient setting?
JC: I think hospitals will become more heavily involved at ASCs and partner with physicians to create these centers with a better patient experience. The patients are driving this. Physicians are having that direct patient care, understanding what the patients need and what the patient expectations are. A lot of patients, especially over the past year, don't want to have surgery at a hospital. That's something that physicians hear as they discuss surgery with their patients. Physicians having that direct patient care are able to guide that care and manage the needs of the patient.
Q: How do you see spine care delivery changing in the next five years?
JC: I think more physicians will lean toward outpatient procedural methods, migrating their cases and right-sizing the needs of the patient to an outpatient or inpatient setting. Physicians and hospitals will be figuring that out. There are procedures that can only be done in hospitals and there are those that should be done in an outpatient or ASC setting. We'll see that playing out more in the next few years.
From CMS, we've seen total hips and total knees being moved to the outpatient setting, so commercial insurance companies are figuring this out as well. CMS is allowing physicians to make that call because they know that physicians are able to better direct patient care. Listening to patients' expectations and needs, providing the best advice or procedure will lead to the best outcome. Physicians will be the ones who have that direct contact with patients to be able to make those calls more effectively.