As spine surgery steadily moves toward outpatient settings, the limiting factors are no longer primarily clinical. Advances in surgical technique, anesthesia and pain management have made far more procedures feasible outside the hospital than in years past, according to Lali Sekhon, MD, PhD, a spine neurosurgeon at Reno (Nev.) Orthopedic Center.
What continues to slow the transition, he said, are economic incentives, reimbursement pressures and entrenched resistance within the healthcare system.
In Dr. Sekhon’s view, the future of outpatient spine care will be shaped less by breakthrough technologies than by how hospitals, payers and policymakers respond to mounting cost pressures, workforce shortages and shifting patient expectations. Those forces, he believes, will ultimately determine how quickly spine surgery moves out of inpatient settings and into ASCs.
A system under strain
Dr. Sekhon was blunt about the pressures facing surgeons and the healthcare workforce more broadly.
“We as surgeons are getting paid less and less,” he said. “They’re paying less and less, but still expecting more and more.”
While reimbursement cuts are not new, Dr. Sekhon said the cumulative effect is changing who enters medicine and how care is delivered. Historically, he said, medicine attracted top talent. He worries that trend is becoming harder to sustain.
“You really want somebody who’s average doing your surgery? Or do you want the best person possible working inside you?” he said. “Reimbursement is a big issue.”
Those financial pressures, he added, ripple through every conversation about site-of-care.
Why outpatient spine surgery moves slowly
From a clinical standpoint, Dr. Sekhon believes outpatient spine surgery is inevitable. From a practical standpoint, he said hospitals and insurers have little incentive to accelerate the shift.
“If you can’t work out why something doesn’t make sense, the answer is money,” he said.
He pointed to the stark cost differences between hospitals and ASCs, noting that procedures can often be performed more safely and at lower cost outside the hospital setting.
“I did a one-level redo lumbar fusion,” he said. “It took me two hours at the hospital, and the hospital sent a bill to insurance for $195,000. The patient stayed one night.”
That revenue, he said, is exactly why hospitals resist moving cases out.
“Through different sources, I found out I generated $20 million in revenue for the trauma center I work at in one year,” he said. “They don’t want to lose that, and that is going to be a big challenge.”
The procedure most likely to move next
Many spine procedures have already transitioned to ambulatory settings, Dr. Sekhon said, including cervical fusions, simple decompressions, spinal cord stimulators and kyphoplasty.
The notable exception is lumbar fusion.
“The one that’s missing is lumbar fusions,” he said. “A one-level lumbar fusion, I think, is an ASC surgery now, and that’s the one that needs to roll over into surgery centers.”
From a surgical and anesthesia perspective, he said, the case is already there. The resistance is not clinical.
Innovation moves incrementally, not dramatically
When it comes to technology, Dr. Sekhon cautioned against expecting a single breakthrough to suddenly expand outpatient spine surgery. “I don’t think there’s one innovation,” he said. “It’s incremental improvements in everything.”
Navigation, minimally invasive techniques, better anesthesia protocols and non-narcotic pain management have all contributed, he said, but none are silver bullets. To explain how implant innovation works, Dr. Sekhon used an analogy far outside the operating room.
“They’re all widgets,” he said. “They’re like Lego blocks.”
He compared modern spinal implants to cars. “If you buy a car today, it’s not the same car it was 20 years ago,” he said. “They’re safer, more reliable, more comfortable. The changes in spinal implants are the same kind of incremental changes.”
Those improvements, he said, aim to reduce the percentage of patients who experience poor outcomes, not eliminate risk entirely. “It’s never going to be 95%,” he said. “But it’s going to be better than it used to be.”
Adoption barriers beyond the operating room
Dr. Sekhon said some of the biggest obstacles to innovation have little to do with surgeons.
Large medical device companies, he said, are no longer driving innovation the way they once did. “The big companies aren’t innovating like they used to,” he said. “They wait until a little company produces something and then they buy them.”
Group purchasing organizations also play a role, he said, making it difficult for smaller companies to introduce new technologies into hospital systems. While ASCs face fewer barriers, contracting with payers remains a significant hurdle.
The role of AI and access
Looking ahead, Dr. Sekhon sees AI becoming unavoidable in healthcare, driven largely by access shortages.
Dr. Sekhon said that as physician shortages worsen, patients will turn to AI tools out of necessity rather than preference. While AI may help streamline care, he said its financial and clinical impact remains uncertain.
“AI has struggled to show that it has value,” he said. “Other than people losing their jobs.”
Patients are already using tools like ChatGPT to research symptoms and treatment options, he added, and he said that trend will only accelerate.
What will ultimately expand outpatient spine care
Rather than a single technological leap, Dr. Sekhon believes outpatient spine surgery will expand through a convergence of factors. Better anesthesia. Smaller incisions. Improved patient education. More sophisticated home care models. “We need to get better at hospital at home,” he said.
If patients can safely receive nursing care and monitoring at home, he said, procedures that once required inpatient stays may become feasible in ambulatory settings.
“That’s the thing that’s going to supplement ASCs,” he said.
A realistic outlook
Dr. Sekhon does not sugarcoat the challenges facing healthcare. He described the system as strained and slow to adapt, but said he remains cautiously hopeful, drawing on a broader perspective shaped by having grown up outside the U.S.
“There’s a lot of good people out there,” he said. “This is a great country.”
If the healthcare system can weather the next few years, he believes the current moment could ultimately prove constructive. “I always like to think that the right and the good things, in the end, they come out,” he said, adding that the period ahead may serve as “a learning lesson for everyone” before things begin to normalize.
