Walter Eckman, MD, founder of Aurora Spine Center in Tupelu, Miss., has been performing a minimally invasive transformaminal lumbar interbody fusion technique in a hospital setting while enabling patient to go home the same day for more than 10 years. He has limited his practice to just minimally invasive spine surgery and maintained profitability, despite his small-town location. Here, Dr. Eckman discusses his technique and the transition of spine surgery into the outpatient setting.
Dr. Eckman's one- or two-level MITLIF technique is performed through a single incision, usually 3 centimeters for single-level procedures and slightly more for multilevel procedures or heavy patients. The procedure is conducted through a 21 millimeter working channel with titanium or polymetric interbody devices. He uses a microscope and limited fluoroscopy to view the patient's anatomy intraoperatively. Either rhBMP-2 or silicated calcium phosphate bone graft substitutes are used to promote fusion. Pedicle screws and rods are inserted through the small working channel under direct vision avoiding more expensive percutaneous screw placement and associated radiation exposure.
"We use a small incision, a smaller access route to the spine and less trauma to the surrounding tissue," says Dr. Eckman. "As a result, patients have less perioperative morbidity and pain than with traditional procedures."
The procedure has the same end result as a traditional TLIF procedure with less-invasive means of achieving fusion. Dr. Eckman recently presented the outcomes of 620 MITLIF procedures in 562 of his patients at the Society for Minimally Invasive Spine Surgery annual meeting. The study evaluated 562 patients with single- or two-level MITLIF between 2003 and 2011. Diagnoses included chronic back pain, stenosis, listhesis, segmental instability and central disc herniation. Here are the results:
• Two patients needed a blood transfusion
• No surgical infections
• 12 procedures needed reoperation
• 95 percent achieved interbody fusion
• 95 percent returned to work
• Two patients returned to work the day after surgery
Dr. Eckman also measured the effectiveness of the procedure, showing that 92 percent of patients had improved visual analog scale back pain scores after one year and 94 percent improved after two years. The average patient had 70 percent improvement in VAS back pain scores after one year, and 68 percent improvement after two years. Upper and lower leg pain VAS scores were also improved in 81-88 percent of patients after one year and with average improvement of 87-90 percent and similar outcomes at two years.
"There are several minimally invasive procedures, such as knee arthroscopy, that are accepted by payors and the public as a standard procedure," says Dr. Eckman. "We still haven't achieved this status in spine. We haven't convinced payors that minimally invasive spine surgery is the better way to go and a lot of surgeons haven't applied it in their practices. The surgeons who do understand this and are moving their patients into ASCs are seeing their patients become mobile quicker with better results than the open technique."
An increasing amount of data, including Dr. Eckman's study, supports the effectiveness of minimally invasive spine surgery techniques performed in an outpatient setting. These surgeries are not only reporting better patient results, but also a lower cost of overall care. Dr. Eckman discusses these advantages and why he feels outpatient spine surgery will soon become the standard of care.
1. Bringing Medicare patients into ASCs. Currently, Medicare will only reimburse for spine surgery performed in a hospital, not in an ASC. "We looked at a group of 191 Medicare patients who underwent spine surgery at the hospital, and some of them were discharged the same day because they were up and moving; they felt good," says Dr. Eckman. "The rest of the patients stayed one to three nights in the hospital. The interesting thing was that the patients who stayed in the hospital even one night had about 5 percent readmission rate for things like bowel problems and pneumonia. Readmissions with these problems led to five to seven additional days in the hospital."
Of the patients who went home the same day, none were readmitted with a subsequent condition. "The Medicare rule is actually dangerous for people, if you can trust our data," Dr. Eckman says. "To me, that's the sort of thing we've got to make a point of to turn around Medicare policy so we can cover these patients at ASCs. Having the surgery in the hospital and staying over night may not be in the patient's best interest in a lot of cases."
2. Lowering the cost of care. Dr. Eckman's technique involves unilateral pedicle screw fixation and a single interbody device, which really lowers the device costs associated with care. "If you can do the whole procedure with one small incision and fixation on one side, you can get the patient up and out of the hospital quickly," he says. "This makes it a cost effective procedure in hospitals and I think things can be done to optimize that in the ASC."
When patients are recovering faster and returning to work quicker, the economic impact from that person's productivity also factors into a cost-savings for overall care.
3. Convincing payors to reimburse well. Over the past few years, many spine surgeons have experienced an uphill battle to receive reimbursement for appropriately indicated surgeries. "The government and payors are saying we perform too many fusions," says Dr. Eckman. "We have data showing that spinal fusions have better long-term outcomes than decompressions for patients with spinal stenosis. We need to change our attitudes to be more flexible about fusions when they could have good outcomes."
He says the best way to prove this point is by conducting long-term studies showing spinal fusions are cost-effective and safe treatments for appropriately indicated patients.
4. Training on the technique. When spine surgeons decide to incorporate minimally invasive spine surgery into their practice, Dr. Eckman says they must be committed to the transition. It takes a lot of time and effort focused away from the regular practice to become proficient in the minimally invasive technique. "I have people visit my practice to see my technique and I can help them learn the procedure," says Dr. Eckman. "If surgeons want more outcomes data, we are amenable to providing that for them as well. I started performing minimally invasive surgery early and have built a good reputation for my work."
However, he cautions surgeons to make sure there is data supporting the efficacy of any technique they learn. "There are so many procedures coming out which people consider 'minimally invasive' but won't be around in five years because the long-term outcomes won't be good," he says. "They might have good outcomes temporarily, but then they'll fall apart. You don't want to jump into performing a procedure just because it's minimally invasive; you want to do a procedure that has good long-term benefits."
5. Advancing good minimally invasive technique. The key to making minimally invasive outpatient spine surgery more pervasive is touting a superior patient experience, says Dr. Eckman. Citing data that shows patients are able to go home and become active the day after surgery; are less likely to have infections; and return to work more quickly with minimally invasive procedures is a good place to start. He encourages surgeons who have good outcomes for outpatient spine surgery to present and publish their outcomes data, and eventually transition their patients to an ASC. If payors and patients see they can have a better outcome with safe outpatient procedures than with traditional open procedures, they will begin to reimburse better and encourage the move.
"We have to convince people there will be a better patient experience with outpatient spine surgery," says Dr. Eckman. "I like to share my story to convince other surgeons to employ the minimally invasive technique. All I do is minimally invasive surgery in a small market, but I still have a good practice. It would be harder to survive if I didn't have this special capability. My situation is a bit of an inspiration for people who really want to do this and carve out a niche for themselves; it shows you what can be done."
Related Articles on Spine Surgery:
Where Spine Research is Headed: 5 Points From Dr. Frank Phillips
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Cost-Effective Spine Surgery: 8 Things to Know
MITLIF technique
Dr. Eckman's one- or two-level MITLIF technique is performed through a single incision, usually 3 centimeters for single-level procedures and slightly more for multilevel procedures or heavy patients. The procedure is conducted through a 21 millimeter working channel with titanium or polymetric interbody devices. He uses a microscope and limited fluoroscopy to view the patient's anatomy intraoperatively. Either rhBMP-2 or silicated calcium phosphate bone graft substitutes are used to promote fusion. Pedicle screws and rods are inserted through the small working channel under direct vision avoiding more expensive percutaneous screw placement and associated radiation exposure.
"We use a small incision, a smaller access route to the spine and less trauma to the surrounding tissue," says Dr. Eckman. "As a result, patients have less perioperative morbidity and pain than with traditional procedures."
The procedure has the same end result as a traditional TLIF procedure with less-invasive means of achieving fusion. Dr. Eckman recently presented the outcomes of 620 MITLIF procedures in 562 of his patients at the Society for Minimally Invasive Spine Surgery annual meeting. The study evaluated 562 patients with single- or two-level MITLIF between 2003 and 2011. Diagnoses included chronic back pain, stenosis, listhesis, segmental instability and central disc herniation. Here are the results:
• Two patients needed a blood transfusion
• No surgical infections
• 12 procedures needed reoperation
• 95 percent achieved interbody fusion
• 95 percent returned to work
• Two patients returned to work the day after surgery
Dr. Eckman also measured the effectiveness of the procedure, showing that 92 percent of patients had improved visual analog scale back pain scores after one year and 94 percent improved after two years. The average patient had 70 percent improvement in VAS back pain scores after one year, and 68 percent improvement after two years. Upper and lower leg pain VAS scores were also improved in 81-88 percent of patients after one year and with average improvement of 87-90 percent and similar outcomes at two years.
"There are several minimally invasive procedures, such as knee arthroscopy, that are accepted by payors and the public as a standard procedure," says Dr. Eckman. "We still haven't achieved this status in spine. We haven't convinced payors that minimally invasive spine surgery is the better way to go and a lot of surgeons haven't applied it in their practices. The surgeons who do understand this and are moving their patients into ASCs are seeing their patients become mobile quicker with better results than the open technique."
Making outpatient spine surgery more pervasive
An increasing amount of data, including Dr. Eckman's study, supports the effectiveness of minimally invasive spine surgery techniques performed in an outpatient setting. These surgeries are not only reporting better patient results, but also a lower cost of overall care. Dr. Eckman discusses these advantages and why he feels outpatient spine surgery will soon become the standard of care.
1. Bringing Medicare patients into ASCs. Currently, Medicare will only reimburse for spine surgery performed in a hospital, not in an ASC. "We looked at a group of 191 Medicare patients who underwent spine surgery at the hospital, and some of them were discharged the same day because they were up and moving; they felt good," says Dr. Eckman. "The rest of the patients stayed one to three nights in the hospital. The interesting thing was that the patients who stayed in the hospital even one night had about 5 percent readmission rate for things like bowel problems and pneumonia. Readmissions with these problems led to five to seven additional days in the hospital."
Of the patients who went home the same day, none were readmitted with a subsequent condition. "The Medicare rule is actually dangerous for people, if you can trust our data," Dr. Eckman says. "To me, that's the sort of thing we've got to make a point of to turn around Medicare policy so we can cover these patients at ASCs. Having the surgery in the hospital and staying over night may not be in the patient's best interest in a lot of cases."
2. Lowering the cost of care. Dr. Eckman's technique involves unilateral pedicle screw fixation and a single interbody device, which really lowers the device costs associated with care. "If you can do the whole procedure with one small incision and fixation on one side, you can get the patient up and out of the hospital quickly," he says. "This makes it a cost effective procedure in hospitals and I think things can be done to optimize that in the ASC."
When patients are recovering faster and returning to work quicker, the economic impact from that person's productivity also factors into a cost-savings for overall care.
3. Convincing payors to reimburse well. Over the past few years, many spine surgeons have experienced an uphill battle to receive reimbursement for appropriately indicated surgeries. "The government and payors are saying we perform too many fusions," says Dr. Eckman. "We have data showing that spinal fusions have better long-term outcomes than decompressions for patients with spinal stenosis. We need to change our attitudes to be more flexible about fusions when they could have good outcomes."
He says the best way to prove this point is by conducting long-term studies showing spinal fusions are cost-effective and safe treatments for appropriately indicated patients.
4. Training on the technique. When spine surgeons decide to incorporate minimally invasive spine surgery into their practice, Dr. Eckman says they must be committed to the transition. It takes a lot of time and effort focused away from the regular practice to become proficient in the minimally invasive technique. "I have people visit my practice to see my technique and I can help them learn the procedure," says Dr. Eckman. "If surgeons want more outcomes data, we are amenable to providing that for them as well. I started performing minimally invasive surgery early and have built a good reputation for my work."
However, he cautions surgeons to make sure there is data supporting the efficacy of any technique they learn. "There are so many procedures coming out which people consider 'minimally invasive' but won't be around in five years because the long-term outcomes won't be good," he says. "They might have good outcomes temporarily, but then they'll fall apart. You don't want to jump into performing a procedure just because it's minimally invasive; you want to do a procedure that has good long-term benefits."
5. Advancing good minimally invasive technique. The key to making minimally invasive outpatient spine surgery more pervasive is touting a superior patient experience, says Dr. Eckman. Citing data that shows patients are able to go home and become active the day after surgery; are less likely to have infections; and return to work more quickly with minimally invasive procedures is a good place to start. He encourages surgeons who have good outcomes for outpatient spine surgery to present and publish their outcomes data, and eventually transition their patients to an ASC. If payors and patients see they can have a better outcome with safe outpatient procedures than with traditional open procedures, they will begin to reimburse better and encourage the move.
"We have to convince people there will be a better patient experience with outpatient spine surgery," says Dr. Eckman. "I like to share my story to convince other surgeons to employ the minimally invasive technique. All I do is minimally invasive surgery in a small market, but I still have a good practice. It would be harder to survive if I didn't have this special capability. My situation is a bit of an inspiration for people who really want to do this and carve out a niche for themselves; it shows you what can be done."
Related Articles on Spine Surgery:
Where Spine Research is Headed: 5 Points From Dr. Frank Phillips
Building a Foundation for Scoliosis Treatment: 3 Important Studies
Cost-Effective Spine Surgery: 8 Things to Know