Eight spine surgeons discuss patient selection for spine surgery in outpatient settings.
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Question: What are the key elements of patient selection for outpatient spine surgery?
Noam Stadlan, MD. Neurosurgeon at NorthShore University HealthSystem's Neurological Institute (Skokie/Evanston, Ill.): The two factors that contribute to successful outpatient spine surgery are the surgery and the patient. Microdiscectomies and small minimally invasive or mini-open lumbar surgeries are ideal cases, as are uncomplicated one- and two-level anterior cervical discectomies with placement of artificial discs or fusions. There is robust data that supports performing these cases on an outpatient basis, as long as the patient does not have significant medical issues.
Patients with significant medical problems such as cardiac or respiratory problems, poorly controlled or insulin-dependent diabetics, the elderly and others are best served by having surgery at a facility where there is an inpatient option. Patient anatomic issues such as obesity should also be considered.
Mark M. Mikhael, MD. Spine Surgeon at NorthShore University HealthSystem's Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): Surgeons should consider three main indications when deciding if a patient is appropriate for outpatient spine surgery. The patient needs to be healthy, motivated and educated. Other than the spine condition, the patient should be without other serious comorbidities like diabetes, pulmonary disease and obesity. The patient must be motivated to go home following surgery and manage pain and other challenges that might arise. Finally, the patient needs pre-, peri- and postsurgical education.
Through streamlined care, the patient must take in comprehensive information on preparing for surgery, potential complications, contacts for follow-up questions and more. Surgeons need all three indications for a successful outpatient surgery. All spinal surgeries — from microdiscectomies to level one and two fusions — can have excellent outcomes in an outpatient setting with healthy, motivated and educated patients. Despite the rapid push toward outpatient surgeries in spine, they are not safe or good for all patients. There always will be a need for inpatient surgical procedures.
Payam Farjoodi, MD. Orthopedic Spine Surgeon at Spine Health Center at MemorialCare Orange Coast Medical Center (Fountain Valley, Calif.): First, making sure you have mastered the surgery itself. Think of common complications and how you would manage these in an outpatient setting.
Second, making sure you choose patients amenable to the outpatient setting. Patients should be counseled and prepared for this, as some have anxiety or pain issues which may make this impossible.
Most importantly, patients should be healthy enough that they pose as minimal a medical risk to anesthesia and surgery as possible.
Rob D. Dickerman, DO, PhD. Director of Neurosurgery at Presbyterian Hospital of Plano (Texas) and Director of Spine Surgery at Medical Center Frisco (Texas): Health and age. Making sure it is a secure fit for all and not just out of convenience.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: By far, a big consideration is the overall health of the patient. You need to have consensus from the staff, anesthesia, the administration and nursing department that operating on a particular patient in an ASC is a good idea. Patient age alone can be a factor, but operating on a diabetic, hypertensive, obese 62-year-old smoker, even for a one-level microdiscectomy may and probably is not worth the risk.
Also, in terms of keeping things safe, I will actually slow down a little during certain phases of the surgery in the ASC cases in order to avoid issues. Taking an extra 10 to 15 minutes to do your dissection carefully or checking another spot-fluoro shot is 100 percent worth it.
Issada Thongtrangan, MD. Orthopedic Spine and Neurosurgeon at Minimally Invasive Spine (Phoenix): Outpatient spine surgery has been a hot topic in the past several years. I always use the shared decision-making between me, the patient and their family members. Patients and their family must understand the nature of surgery and the outpatient postoperative course — they are totally different between outpatient versus inpatient spine surgery. Patients and their family member must understand the concept of early ambulation, minimizing opiates medications, utilizing multi-modal pain management. They also must understand and be able to notice signs and symptoms of early postoperative complications related to their surgery.
In my practice, our team will call and follow up with the patient and their family that night and the next two to three days to make sure they do not have any complications and to coach them through their postoperative courses.
Another important factor is their health. I usually review their medical problems, medications, BMI, sleep apnea, etcetera. For example, there are several studies demonstrating the high complications in high BMI patients, patients who are above ASA 2, patients with poorly controlled diabetes, etcetera. Age is not an absolute contraindication for outpatient surgery for me, but rather their physiologic age and their health. I found a modified frailty index is a helpful tool to evaluate those elderly patients. Additionally, in my practice, we have a multidisciplinary team involving the surgeon, anesthesiologist and operating room nurses, who review the challenging cases and make the final decision so the surgeon has accountability, and we make sure that patients are safe.
Raj Arakal, MD. Orthopedic Spine Surgeon at the Texas Back Institute (Plano): Medical history is critical to assess perioperative risk. The outpatient setting is not the best arena to tackle patients who have significant cardiac, pulmonary risk or ones who are battling obesity. Additionally, mitigating risk and potential complications from anesthetic risk is significant.
The nature of the surgery should be carefully reviewed for possible blood loss and need for replacement.
Perioperative pain control and immediate risks for over sedation and or late sedation and respiratory risk are all critical factors in the decision making.
Peter Derman, MD. Spine Surgeon at Texas Back Institute (Plano): With advances in minimally invasive techniques, anesthesia and multimodal analgesia, patients can increasingly reap the benefits of spine surgery on an outpatient basis. Careful patient selection is essential to ensuring that this can be achieved safely and reproducibly. Patients with medical comorbidities such as obstructive sleep apnea, cardiac disease, significant obesity or previous stroke are not optimal candidates for outpatient surgery and are likely better monitored at least overnight.
Patients must have sufficient social support and psychological coping mechanisms to successfully recover at home. Prolonged operative time has also been associated with poorer outcomes, so surgeons considering outpatient procedures must conduct an honest self-assessment as to whether they consistently perform such operations in a predictable and time-efficient manner. The aforementioned considerations are even more critical if operating in an ASC, where conversion to inpatient status is more difficult. By adhering to these guidelines, however, patients can be discharged safely on the day of surgery to enjoy the comfort of their own homes.