As many spine procedures become more minimally invasive, they’re also in a good position to grow in the ASC 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. Becker’s invites all spine surgeon and specialist responses.
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Please send responses to Carly Behm at cbehm@beckershealthcare.com by 5 p.m. CST Tuesday, March 18.
Editor’s note: Responses were lightly edited for clarity and length.
Question: What spine procedure do you think will see an increased case volume in the outpatient setting?
Brian Fiani, DO. Spine Surgeon. (Birmingham, Mich.): Anterior lumbar interbody fusions. With literature showing this technique having less blood loss, lower hospitalization length of stay, and better postoperative pain scores, it’s an ideal surgery to integrate into the surgery center as long as you have experienced access surgeons and ideal patient selection.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Sacroiliac joint fusion is more or less done now in ASCs. I think as we get better as a group understanding the right way to diagnose this smaller subset of patients, the volume will increase. We already see a number of ASCs with their own frameless navigation hardware and there will be an uptick in cases.
Brandon Hirsch, MD. DISC Sports & Spine Center (Newport Beach, Calif.): As far as growth of a specific spine surgery procedure in the outpatient setting, I believe hands-down the most growth will be in spinal endoscopy. The technology is advancing rapidly and patients are always seeking less and less invasive methods of surgery. Economic barriers aside, spinal endoscopy is well suited for the surgery center environment due to the relatively short length of the procedures, minimal postoperative pain, and minimal need for intraoperative and postoperative narcotics.
Many surgery centers already have arthroscopic equipment in place that can also be utilized in spinal endoscopy. I do also believe that cervical disc replacement will continue to see growth in the outpatient setting as surgeons continue to increase their comfort level with anterior cervical exposures on an outpatient basis.
Mohammed Khan, MD. New Jersey Brain & Spine (Hackensack): Ultra-minimally invasive endoscopic spine surgery is a rapidly advancing field with procedures such as endoscopic discectomies, foraminotomies and even fusions gaining traction. These techniques allow for same-day discharge while minimizing disruption to the paraspinal musculature, leading to faster recovery, reduced postoperative pain, and improved patient outcomes.
Choll Kim, MD, PhD. Excel Spine (San Diego): That is an easy one…LESS, lumbar endoscopic spine surgery, which you have to admit is a very compelling name for a minimally invasive procedure. After many years of struggling with adoption, I see the new generation of spine surgeons embracing this technology. More importantly, the ASC will see an entirely new group of spine surgeons emerge. This new generation of spine surgeons will spend most of their time ASC, similar to our orthopaedic sports medicine colleagues. Just as some knees are treated endoscopically by “sport medicine” surgeons while others are treated open by our “joint replacement” colleagues, it will not be long before we have two types of spine surgeons…one will do most of their work in the ASC and the other will do most of their work in the hospital.
Jeff Lehmen, MD. SSM Health Spine Surgery Center (Jefferson City, Mo.): Minimally invasive lateral interbody fusions (LLIF) I expect will be performed more frequently in ambulatory surgery centers (ASCs) due to advancements in surgical techniques, anesthesia, and patient selection criteria. I have been doing this for quite some time and the results have been great. Posterior fixation with or without lateral fixation can be added in the same position or prone depending on surgeon preference and whether it is a prone or lateral procedure. These procedures offer a very delicate exposure with reduced tissue disruption, very little blood loss, and faster recovery times compared to traditional open spine surgeries, making them well-suited for the outpatient setting.
Furthermore, there is no need to mobilize major vessels to perform this surgery. Improvements in navigation technology and neuromonitoring have enhanced the safety and efficiency of LLIF, allowing surgeons to operate with greater precision. Additionally, as ASCs continue to adopt enhanced recovery protocols and cost-effective care models, more spine surgeons are shifting toward performing LLIF in these centers to provide high-quality, value-based care for appropriately selected patients.
Don Park, MD. UCI Health (Orange, Calif.): The spine procedure that will see an increased case volume in the outpatient setting is outpatient lumbar fusion. Using specialized techniques such as lateral lumbar and oblique lumbar approaches, minimally invasive transforaminal lumbar interbody fusion, and even endoscopic fusion, surgeons can now perform minimally invasive lumbar fusion with much less pain and faster recovery as compared to open surgery. As more spine surgeons become facile with advanced endoscopic techniques, the improvements in postoperative pain and recovery will become greater and greater.
Advanced technology such as computer navigation and augmented reality can accurately and efficiently place spinal instrumentation with very small incisions that are precise and well planned. By implementing standardized outpatient Enhanced Recovery After Surgery (ERAS) protocols, patients can have significantly less pain with lumbar fusion, especially when combined with minimally invasive techniques. Part of the outpatient ERAS protocols is the implementation of pain blocks such as erector spinae blocks, which has been shown to provide significant pain reduction after spine surgery. Combining all of these advanced techniques have allowed lumbar fusion to be possible and successful in the outpatient setting with medically appropriate patients.
As financial considerations become more and more important in spine surgery, shifting lumbar fusions to the outpatient setting can significantly reduce cost and improve efficiency, while still providing high level care with similar outcomes and low complication rates.
Scott Raffa, MD. Cantor Spine Center (Fort Lauderdale, Fla.): One can anticipate increased case volumes in the outpatient setting of artificial disc replacements as well as transforaminal interbody fusions and lateral lumbar interbody fusions.
The above listed approaches and procedures will continue to become more expeditious intraoperatively, and in the patient recovery/be more tolerated, with continued incremental updates and technique etc.
Noam Stadlan, MD. Endeavor Health Neurosciences Institute (Skokie and Highland Park, Ill.): The limiting factors for outpatient surgery are rapid discharge and a comfort level that the patients do not require further monitoring. The usual impediments to rapid discharge are either pain or medical problems. As more procedures are done with smaller and less invasive incisions, more and more procedures can at least theoretically be done in the outpatient setting. I think that the fact that they can be done should not automatically mean they should be done in the outpatient setting if the patient requires monitoring either from a medical or neurological perspective. Moving from inpatient to outpatient should not occur at the price of safety.
Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): As spinal surgery and in-patient reimbursements continue to decline, there will be those more straightforward and uncomplicated procedures rendered/managed as outpatient status. Taking into account patient selectivity and comorbidities, the more infirmed patients will be excluded from any day-surgery-center scenario. These folks are usually bundled together and cared for in larger, better equipped healthcare systems. Inclusive to this list will be unburdened anterior cervical fusions, multilevel laminectomies of both cervical approaches and unincumbered lumbar fusions.
