Dr. Amy Wickman on the 'great potential' of outpatient spine surgery

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Moving transforaminal lumbar interbody fusions to the ASC was one of the proudest accomplishments for Amy Wickman, MD, of Alta Orthopaedics in Santa Barbara, Calif.

Dr. Wickman spoke with Becker's about how the practice brought the procedure to the ASC and obstacles she anticipates for outpatient spine migration.

Note: This conversation was lightly edited for clarity.

Q: Can you provide insight into that process of migrating TLIFs into the outpatient settings? 

Dr. Amy Wickman: It's been well documented at Rush in Chicago for many years, and I used their medicine protocol for postoperative meds, along with talking to people who have done it before. We started doing erector spinae blocks in the ASC for about a year now, and even for nonfusion cases, it's a game changer in post-op pain control. It definitely has reduced narcotic intake significantly. 

Then as we're seeing across the country with healthcare trends, there's either shortage of staff available and/or people who are pretty burnt out, especially in the hospitals. So I think it makes for a great opportunity for patients to be able to care for themselves at home and probably have a little bit of a better recovery period. They tend to be really good with staying on top of their medications and getting up and about for walks, as opposed to being in the hospital where maybe they have to wait a half an hour or 45 minutes for someone to bring them their medications. I think it just has great potential to actually make the recovery for patients much better.

Q: What have been some of the specific outcomes that you've seen with patients and finances so far?

AW: It's interesting. I haven't done a study on this, but I've seen the trend that I saw with the outpatient fusions where their pain control is much better because they're in charge of a charge of it themselves, and they're much more motivated population to get moving and going at home and get off their pain meds. So likewise I've seen constipation and impaction to be much less than what we've seen in the hospitals from using less narcotics for a shorter period of time. 

In terms of the financial aspects of it, that's a little bit challenging. One of the challenges that I have come across is that it took a lot of work because the instrumentation for TLIFs is rather expensive. It took a lot of work and negotiating prices for instrumentation used at an ASC, because the prices for the hospital just are not applicable nor doable at an ASC. So that was a learning curve for myself, and definitely an interesting challenge that I was not anticipating. The other challenge is as of right now, Medicare does not cover outpatient fusions. Our local version of what other people know as Medicaid also follows Medicare guidelines, and they don't cover it in the outpatient as well. 

Q: What are the costs involved with instrumentation? What strategies help with cost negotiations?

AW: The implants can be expensive, especially when you're using expandable cages and headless screws with retractor systems attached to it. I think the conversation is centered around changing your allograft properties that you might use in the hospital might not be what you use in the ASC. You might have to take some of your own bone graft more. In terms of negotiating prices, ideally a surgeon can do more cases more quickly in an ASC than they can at the hospital. So even giving a discount on instrumentation in the long run should help facilitate overall increase in the number of cases. So while the industry may not get as much per case, they hopefully are seeing more cases done. That's been at least some of the incentive that I have used to help negotiate costs on implants at the surgery center at the ASC.

Q: What are some other spine procedures that you think are best poised to move to the ASC?

AW: The XLIF and lateral direct approach is also a good option for the ASC, although those haven't been approved by Medicare yet. There are a lot of other spine cases that aren't approved by Medicare. Another code that Medicare hasn't approved is facet system resections in the outpatient ASC. That is such a small, minimally invasive surgery that it should be a no-brainer to be allowed in the ASC. Hopefully in these next couple of years, we'll see Medicare and Medicare guidelines become more up to date with what is acceptable for the surgery center.

Q: What are some other spine technologies that you're most excited about?

AW: There are some things on the horizon that are coming that allow for accurate pedicle screw placement that might be applicable to the ASC. Obviously, navigation and robotics is not as easy to do in the ASC because of the price limiting factor with how expensive that technology is. I think we all would like an efficient yet reliable way to place instrumentation in a minimally invasive fashion that doesn't have as much radiation. So I think there's some interesting technologies coming out in the next couple of months to years that can incorporate that. Technology ultimately will help us move forward in making better patient outcomes and better, safer surgeries for both the patients and then all of the staff within the OR, from the anesthesiologist to the scrub tech to the circulating nurse.

Q: What other healthcare trends are you following, and what are you looking forward to in 2024?

AW: I'd love to hear what other people across the country are thinking. I'm in Santa Barbara County, which is outside of Los Angeles, and during the COVID-19 pandemic, many people moved out of the large cities into smaller populations. At the same time, we saw a loss in healthcare professionals up to 25% to 30%. Over these next couple of years it'll be interesting to see how this plays out and whether populations shift back to the major urban centers, or if we have people that are willing to go back into the healthcare services. It definitely has pushed surgery wait times out longer, imaging wait times out longer and physical therapy shortages. It all around has affected healthcare and its environment today. Whether that's a direct effect of the pandemic, I don't know. But we certainly are seeing changes that we did not have pre-pandemic.

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