Which spine surgeries are becoming more prevalent at ASCs?

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Spine and orthopedic procedures once considered complex — and often requiring days of recovery in the hospital — are now being performed at ASCs, with patients going home the same day.

Over the past decade, spinal fusions, disc replacements and total joint replacements have been among the orthopedic procedures that migrated to the outpatient setting, along with many other higher-acuity cases.

"If you take 2018 to 2021, [there has been] 30-plus percent growth in orthopedics in terms of surgery center volume, and spine is about 200 percent. These are two of the faster growing specialties in all of medicine," according to Nader Samii, CEO of Chesterfield, Mo .-based National Medical Billing Services.

Here are some of the most prominent spine surgeries accelerating to the outpatient setting:

1. Multilevel fusions. Three-level 360-degree fusions and anterior cervical discectomy and fusions are some of the more complex cases migrating to ASCs. Earlier this year, one of the first outpatient three-level lumbar fusions was performed by Jeffrey Carlson, MD, at Orthopaedic & Spine Center in Newport News, Va. Over the past decade, innovations in technique and technology have allowed surgeons to move more complex cases to the surgery center and achieve positive outcomes.

"We've gone from single-level to two-level and now three-level all, through a small incision," Dr. Carlson told Becker's. "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."

2. Robotic procedures. Robotic-assisted surgeries are expected to become more prominent at ASCs. Hospitals are less likely to shell out the capital for robots when so many spine and orthopedic cases are shifting away from the inpatient setting.

"As technologies improve and space and affordability barriers are addressed," more ASCs may incorporate robots for spine and total joint procedures, according to Nate Garner, administrator of Fort Sutter Surgery Center in Sacramento, Calif. 

Many medtech companies are also rethinking business models in the new normal. "They may link it to how many cases you do, which can help pay it down and develop various 'at risk' models,'' Martin Roche, MD, of HSS Florida in West Palm Beach, told Becker's. I think orthopedic companies are drawing up different types of business models because they see robotics as the future as well."

3. Multilevel disc replacement. Artificial disc replacement, performed as an alternative to spinal fusion, allows patients to retain mobility in the cervical and lumbar spine. The first case in the U.S. was done 21 years ago at Texas Back Institute in Plano, with recent long-term follow-up studies demonstrating the safety and effectiveness of these devices over fusion.

Now, with improved technology and protocols, more surgeons are performing multilevel fusions at ASCs. "One- and two-level disc replacement patients can often resume low-impact activities within weeks of the procedure," according to Todd Lanman, MD, of Beverly Hills, Calif.-based Lanman Spinal Neurosurgery, but "three- and four-level procedures have longer operative time and require more recovery time." Patients undergoing three- or four-level cases are often strong enough to leave the surgery center the same day and recover within two to three months, Dr. Lanman said.

4. Endoscopic spine surgery. Many surgeons expect endoscopy to play a large role in the future of outpatient spine surgery. Previously, spinal endoscopy was only used to address disc herniations, but is now used to treat a variety of more complex cases, resulting in less muscle damage and quicker recoveries for patients.

"While patients with spinal deformities will likely continue to receive inpatient care due to the complexity of their treatment, many of the treatments for common degenerative conditions will continue to migrate to lower-cost care settings," according to Brandon Hirsch of The CORE Institute in Mesa, Ariz. "Endoscopic visualization and instruments have become highly advanced and, in many cases, allow for targeted treatment of stenosis on an ambulatory basis."

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