Awake spinal fusion, posterior cervical laminoplasty and more: Spine procedures best poised for the ASC


ASCs and outpatient surgery have the benefit of letting patients recover at home the same day they go to the operating room. While many spine techniques are becoming less invasive, migrating cases to ASCs can take time.

Seven spine surgeons share what they believe will be headed to the outpatient center next.

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: Responses were lightly edited for clarity and length.

Question: What spine procedure is best poised to move to the ASC next?

Chester Donnally, MD. Texas Spine Consultants (Dallas): So many are already being done in an ASC that it really sets the bar high. I feel like on LinkedIn you will see a surgeon post how great they were to do a four-level lateral with perc screws and send the patient home that day from (their) ASC. The bar has been set very high for outpatient cases.

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): Posterior cervical laminoplasty and single level anterior lumbar interbody fusion could be two procedures that are poised to move to the ambulatory surgery centers next. With proper postoperative observation for several hours in the recovery unit, family at home with the patient for continued observation, and dedicated postoperative home nursing visitation on postoperative day one, there could be consideration to perform these at surgery centers.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Most single-level interbody fusions, I believe, will be done in ASCs in the next 10 years. We are already seeing them, for the most part. But I think with single position surgery and endoscopic fusions, we will see these more often done at ASCs with lower cost and better patient and surgeon experiences.  

Sohaib Hashmi, MD. UCI Health (Orange, Calif.): Prone transpsoas lateral interbody fusion is most likely to have a larger footprint in ambulatory surgery centers. Single-level PTP procedures are currently performed in ASC settings; however, there are several factors why there will be an even greater shift of PTP to the outpatient setting.

Simplicity of prone positioning streamlines setup and turnover of the procedure for staff as well as minimizing diverse equipment needs in the ASC. Simultaneous minimally invasive access to the anterior and posterior columns of the spine allows for predictable outcomes in treatment of lumbar spinal stenosis and instability. Indirect decompression of neurologic stenosis allows for percutaneous posterior instrumentation insertion. Also, prone positioning allows for concurrent anterior spinal column work and posterior spinal instrumentation placement with or without enabling technology. It also offers efficient and short surgical duration, which allows for optimizing resource utilization with multiple PTP procedures performed throughout the day.

By meeting these key criteria, PTP will prove to be a safe and effective surgical option for patients at ASCs, offering the benefits of a minimally invasive approach, shorter recovery time, and reduced healthcare costs compared to traditional hospital-based procedures. 

Richard Kube II, MD. Prairie Spine & Pain Institute (Peoria, Ill.): I have been doing ambulatory spine surgery exclusively since the fall of 2014. For that vantage point, I feel I am already doing all that can be done. Deformity and other larger cases are the only cases we do not do in the ambulatory setting, and those decisions are based more upon medical risk factors, need for transfusions, etc. In those instances, I think it will be a long time before those types of cases can be considered for outpatient facilities. Some procedures in their current format require the added capabilities a hospital setting provides for medical comorbidities as well as transfusion capabilities and convalescent care.

Alok Sharan, MD. Spine and Performance Institute (Edison, N.J.): Traditionally, laminectomies and ACDFs were performed comfortably in ASCs. As incisions became smaller and anesthesia improved, there has been a slow migration of lumbar fusions to ASCs. As regional anesthesia becomes more prevalent, we will see that surgeons will become more comfortable performing single- and two-level lumbar fusions in the ASC.

For the majority of our patients who undergo awake spinal fusion, they go home within a few hours after surgery and are off narcotics within a few days. By avoiding general anesthesia, patients face less delirium and confusion after surgery, giving them greater confidence to go home. Performing the regional paraspinal blocks with Exparel has led to patients having less pain after surgery, allowing them a comfortable and quicker recovery. Overall this has given everyone greater confidence to allow the patients to go home. Our goal now is to move the majority of our awake spinal fusion cases to an ASC.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The most likely procedures would be cervical and lumbar fusions with accompanying anesthesia and nursing support. Since these procedures have now become near-routine and outcomes being surgeon-dependent and measured, most patients are discharged the same or next day depending on comorbid status. 

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