Over the next five years, minimally invasive technologies such as robotics and endoscopy are expected to become more prominent in spine surgery, and hospitals may be used only for complex cases on patients with significant comorbidities.
Five surgeons discuss the future of spine care in the outpatient setting and how they see technology evolving in the specialty.
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. Becker's invites all spine surgeon and specialist responses.
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Editor's note: The following responses were lightly edited for style and clarity.
Question: In five years' time, what will outpatient spine surgery look like?
Grant Shifflett, MD. DISC Sports & Spine Center (Newport Beach, Calif.): How about what I hope to see? My hope would be that we look back in five years congratulating ourselves for the monumental progress we have made in shifting cases to the outpatient world, and see these past couple years as a tipping point in that precipitous movement. I hope providers will find themselves having difficulty finding reasons to do spine cases in the hospital. I hope insurers will see the incredible cost savings and the value add of shifting volume out of the hospitals. I also hope that providers who make wise decisions about treating patients with minimally invasive and motion-preserving techniques are recognized and rewarded by the system. I think if you’re not on the train that’s moving patients to the outpatient environment now, you’ll be in an increasingly isolated position in five years.
Michael Goldsmith, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): We currently perform the majority of cervical disc arthroplasty and lumbar discectomy/laminectomy surgeries, as well as select lumbar fusions, in the outpatient setting. Over the next five years, I anticipate the volume of lumbar fusions performed in the outpatient setting will significantly increase. To accomplish this, spine surgeons will need to work alongside anesthesiologists to control pre- and postoperative pain to allow the patient to mobilize and return home more quickly. Communicating with patients about the expectations of a successful outcome of a lumbar fusion in the outpatient setting will also be key to this transition.
Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): I anticipate that more spine surgeries will be performed at ASCs. There will be more investment in less-disruptive surgery such as endoscopy, navigation, robotics, etc. However, the more complex cases or high-risk cases such as major deformities, tumors and infections will still be performed in the hospital. In the ASC setting, there will be more collaboration among specialists. Anesthesiologists or CRNAs will help to do postoperative blocks like erector spinae or [transversus abdominis plane] blocks. There also will be a significant reduction in opioid use. Physical medicine will help with prehab and the acute post-op phase.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: I believe we will see a large amount of spine surgery volume being done outpatient. As endoscopic procedures get more popular and prevalent, we may see more of those done as well. What I hope to see is more anterior lumbar fusions and arthroplasties done at ASCs. The comfort level of both approach surgeons and the spine surgeons will most likely grow in the future, and I think payers will really start to see the value in these procedures being done in an ASC.
Christian Zimmerman, MD. Saint Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): As a result of the crisis-mode status borne out of the many COVID-19 surges, archetypical changes have subsequently resulted in practice patterns and admission/discharge rates in spinal surgery. Recent retrospective reviews in our specialty spine clinics revealed significant changes in admission criteria, procedural designation, length of stay and outcome follow-through for outpatient surgical designations. While the front-end preparatory work remains dogged, the approval and scheduling process is more cumbersome and involved from a staffing requirement.
Intramural discussions about treatment options and postoperative care includes both provider and advanced practitioner information-sharing about expected length of stay and clearance for discharge. This includes spinal fusion patients who qualify through physical/occupational clearance evaluations at postsurgical end. Granted, with past promotional metrics including length of stay for years, the cost containment of this healthcare piece has shifted again. These changes are current and will continue to encourage more same-day surgical allowance per patient notification, acceptance and comorbid variability.