Three spine surgeons weigh in what patient characteristics they consider important when deciding whether to perform a surgery in the outpatient setting.
Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.
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Note: The following responses were edited for length and clarity.
Question: What are some key patient evaluation considerations when performing outpatient spine surgery?
Jeremy S. Smith, MD. Director of the Spine Surgery Fellowship at Hoag Orthopedic Institute (Orange, Calif.): The preoperative screening and risk assessment is paramount. Any patient with extensive risk or chronic medical comorbidity may not be a candidate. Factors known to increase patient morbidity and the risk of hospital admission include:
• Patient age greater than 85 years
• Operative time greater than one hour
• Heart disease
• History of malignancy
• Peripheral vascular disease
Some conditions may be undiagnosed but pose significant risk and must be suspected in every preoperative evaluation. These include:
• Obstructive sleep apnea
• Cardiovascular disease
• Chronic obstructive pulmonary disease
• End-stage renal disease
If there is suspicion on the initial evaluation, clearance with the appropriate specialist is necessary and may necessitate performing the surgery in the inpatient setting.
The preoperative assessment and screening must include a basic physical assessment, allergies, history of reaction to anesthesia, cultural, emotional and socioeconomic assessment, signs of neglect or abuse, pain assessment and medication assessment.
The patient must understand their disposition following surgery and must plan accordingly. Teaching protocols for wound care [and] physical therapy is necessary preoperatively. If the patient does not have anyone to assist with basic activities of daily living, arrangements should be made before surgery.
The patient must be [given] expectations for pain control and function following surgery. If they do not have a basic understanding, there is a chance they may require admission to an inpatient facility. Having realistic expectations is paramount to having a successful outpatient procedure.
Lastly, the patient must be counseled on the potential adverse events and the signs and symptoms of a complication. This is critical, and if there is a suspicion that the patient may be a poor judge of their condition, inpatient surgery may be safer.
Brian R. Gantwerker, MD. Founder of the Craniospinal Center of Los Angeles: Patients should be evaluated on the basis of overall health, planned procedure, potential complications with the procedure and their manageability should they happen. There are excellent tools available, such as the American College of Surgeons' Risk Calculator, that can aid in determining the overall risk for a potential patient. I have an inverse age rule — the older the patient, the shorter the operation.
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 [method,] between me, the patient and their family members. Patients and their family must understand the nature of surgery and the outpatient postoperative course. These are totally different between outpatient and inpatient spine surgery. Patients and their family members must understand the concept of early ambulation, minimizing opiate medications, utilizing multimodal pain management and so on. 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 for 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, comorbidities, sleep apnea, etc. For example, there are several studies demonstrating the high complications in high BMI patients, patients with an American Society of Anesthesiologists' score of above two, patients with poor controlled diabetes, etc.
Age is not an absolute contraindication for outpatient surgery for me, but rather [I look at] their physiologic age and their health. I found the Modified Frailty Index is a helpful tool to evaluate those elderly patients. Additionally, in my practice, we have a multidisciplinary team that involves a surgeon, anesthesiologist, operating room nurses to review the challenging cases and make the final decision, so the surgeon has accountability and we make sure that patients are safe.