The future of outpatient spine surgery is becoming more accommodating to complex spine surgery, and for one surgeon a mini-open cortical trajectory technique has helped make previously challenging cases more feasible in the ASC.
Michael Burdi, MD, has leveraged this approach in hundreds of cases since 2016, and some cases include multilevel posterior lumbar fusions. Dr. Burdi, of DISC Newport Beach (Calif.), discussed his journey with the cortical trajectory technique and how it’s advancing outpatient spine surgery.
Note: This conversation was lightly edited.
Question: What first convinced you that the cortical trajectory technique could make same-day or next-day discharge realistic for these patients, and what was the reaction from your colleagues at the time?
Dr. Michael Burdi: I was convinced about 12 years ago, when some of the companies were just introducing cortical trajectory techniques. It was clear that the medial-to-lateral approach allowed us to reduce the incision size substantially, reducing tissue disruption and promoting quicker recovery. This aligned well with the minimally invasive practices at surgery centers.
Q: How do you decide which patients are candidates for the ASC setting versus a hospital? Where does a 3-level fusion fall on that spectrum?
MB: Patient selection is vital. With the same determination you would use for anyone undergoing anesthesia or having complex surgery, you have to select your patients carefully. If somebody is critically ill, you probably won’t do that case at the surgery center, but for healthier patients, a three-level fusion can definitely be done at a surgery center. Most of my surgeries at the ASC are one- and two-levels, with three-level fusions making up about 5% of my ASC case mix. While we tend to do fewer three-level fusions simply because these cases have more complicated things going on most of the time, you could certainly do a straightforward three-level at a surgery center, especially at a highly specialized, well-equipped ASC like DISC.
Q: You place a strong emphasis on getting patients healthy before they ever enter the OR. How do you structure that process with primary care and specialist physicians?
MB: Having a case canceled because somebody isn’t teed up for surgery is awful, and it’s a waste of everybody’s time. I really prepare my patients well if they have any comorbidities. For example, if a patient has heart disease, they automatically need not just primary care clearance, but cardiac clearance as well. We don’t want the patient to show up to surgery and have surprises. We conduct our pre-op on those patients a week before surgery, so if there are any loose ends, we have enough time to address them. By the time the patient comes to surgery, they’re teed up and ready to go with no loose ends. I have a very, very low case cancellation rate.
Q: When working with older patients, what extra considerations are you thinking about on the technical and logistical side to make outpatient surgery work for them?
MB: Obviously, with older patients, it becomes vital that you examine them and their individual circumstances more closely. With an older patient, a surgery center might not be ideal for a three-level fusion. I’m not saying it’s impossible. I’ve actually performed a two-level fusion on an 84-year-old patient, but that’s an exception to the rule. With older patients, you have to consider comorbidities that might indicate that a case is better for the hospital.
You want to do what’s best for the patient. I will frequently check bone-density scans ahead of time to make sure I don’t get a case at a surgery center with somebody who has really mushy bones. Take the time to select the appropriate patients, get the appropriate pre-op workup, and make sure the case is appropriate for a surgery center.
Q: What does an ASC actually need in terms of staff, equipment and protocols to safely support posterior lumbar fusions at this level of complexity? Where do most ASCs fall short today?
MB: You must have the right infrastructure. I do all my decompressions under a microscope, and DISC has excellent microscopes, since the founder works closely with Zeiss. For posterior lumbar, you usually need a microscope and other advanced guidance/imaging equipment, which our surgery centers do. DISC is receptive to facilitating the performance of posterior lumbar cases.
Q: What are the remaining barriers to moving more complex spine cases to the outpatient or 23-hour stay?
MB: One of the big barriers is obviously being able to perform these surgeries less invasively enough to take place in the ASC. I don’t like the word “minimally invasive” because for years minimally invasive cases involved just putting in screws percutaneously. In truth, a lot of posterior spine surgeries require you to make an incision and open up the spine, which you can’t do percutaneously. But you can use smaller retractions, and the cortical technique allows you to do that.
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