Spine surgery still has room to grow in the outpatient setting. As minimally invasive techniques and navigation technologies evolve, some spine surgeons have considered taking the leap into the ASC setting. Four spine surgeons shared their insights on outpatient spine surgery and implementing it in the ASC:
- Brian Gantwerker, MD. The Craniospinal Center of Los Angeles
- Ray Gardocki, MD. Vanderbilt Spine (Nashville, Tenn.)
- Lali Sekhon, MD, PhD. Reno (Nev.) Orthopedic Center
- Vladimir Sinkov, MD. Sinkov Spine (Las Vegas)
Note: Responses were lightly edited for clarity.
Question: What spine procedures do you expect will become more prominent in the ASC setting over the next three years?
Dr. Brian Gantwerker: Over the next three years or so, we will see a steady increase in procedures such as lateral interbody fusion and 1- and 2-level cervical and lumbar arthroplasty. There is still a push to have patients have surgery in a safe setting with the ability to observe them for 23 hours and allow them to go home after. Endoscopic surgery is also an interesting field, but there is some significant start-up cost associated with it, and no unique CPT code associated with it as of now. There is not a bigger reimbursement delta to offset the risk of acquiring the equipment and not doing enough cases to get the proper ROI.
Dr. Ray Gardocki: I believe there will be more ASC-based instrumented lumbar fusion performed as well as the full gamut of endoscopic spine procedures. Ambulatory endoscopic spine surgery can be used to address cervical foraminal stenosis (from disc or osteophyte), thoracic disc herniations (soft and calcified), lumbar discectomies, decompressions and even interbody fusions. As the ratio of endoscopic interbody fusions increases, many of these procedures will migrate to the ASC.
Dr. Lali Sekhon: Anterior cervical discectomy and fusions, simple decompressions — both cervical and lumbar — and spinal cord stimulators all get done in ASCs from a spine perspective. The next goal is lumbar fusions at 1 and 2 levels performed from any approach. Just like our orthopedic colleagues, lumbar fusions will become a 23-hour or same-day surgery. Cheaper outpatient spinal navigation will facilitate this.
Dr. Vladimir Sinkov: I believe lumbar decompressions, cervical fusion and disc replacements, and (to a lesser degree) minimally invasive lumbar fusions will become more prominent.
Q: What are your tips for migrating these procedures to the ASC? What technologies or case approaches do you recommend in safely and effectively performing these cases in outpatient settings?
BG: Patient selection remains key in doing ASC cases. It is important if the patient falls into a higher risk echelon that they be recommended for surgery in the inpatient setting. Additional tips to get patients to the ASC is hiring and maintaining properly trained staff in the OR. Selecting for very experienced staff at all phases of care will pay off in great dividends.
Technology is a double-edged sword. On the one hand it makes some surgeries deceptively simple, but in the wrong hands, it can lull some of the untrained into a false sense of security. There are a plethora of technologies on the market that are not necessarily good for patients and are being used somewhat irresponsibly and in potentially inappropriate cases. I would caution ASC managers and administrators to look at these with a somewhat jaundiced eye and use caution when dealing with those who seem to be selling a bill of goods
RG: Minimally invasive and endoscopic techniques which minimize pain and morbidity while still achieving the fundamental operative goals are the primary tools to migrate cases to the ASC. Regional blocks and neuraxial anesthesia can also be helpful, especially in elderly patients or those with increased co-morbidities.
LS: Navigation makes lumbar fusions, especially minimally invasive transforaminal lumbar interbody fusions and laterals, much easier. “NAV in a box” will greatly enhance the transition.
VS: The main issue is proper patient selection in terms of their overall health, risk of complications, ability to mobilize quickly after the surgery, and reasonable expectations. The other important issue is achieving proper postoperative pain and nausea control by working with the anesthesiologist to develop optimal pre-, intra- and postoperative protocols.
Q: What are your key considerations when migrating spine procedures to the ASC?
BG: I go for cases that tend to be short and straightforward. No one wants to be in the operating room all day in the ASC — not me, the patient, anesthesiologist, nor the staff. Try to keep the cases “short and sweet” to maximize case flow and simplicity of post-op care.
RG: Ask yourself: Can the procedure be safely done in the outpatient setting without increasing risk? If the answer is yes, then that case can be done outpatient. The outpatient also needs some support at home. There will still be complications wherever procedures are done; you just can’t compromise your ability to deal with them.
LS: Health of the patient is key. Chronic pain and morbid obesity are best initially avoided. Anyone who needs rehab or skilled nursing or with no home support is best done in the hospital.
VS: First is to make sure that proper equipment is available and staff is properly trained. Second is to make sure it is financially feasible by analyzing reimbursements versus supply, implant and staffing costs.
Q: How can spine surgeons consistently ensure excellent patient outcomes in the ASC?
BG: With a focus on patient experience, case appropriateness, good surgeons and interventional pain physicians, and negotiating commensurate reimbursements with the payers, I think success will be likely. If you are falling short, or things are not going well, look for opportunities in case selection, pre-op clearance, or surgical factors that may be hampering you.
RG: Proper surgical indications and techniques that achieve the fundamental goals of surgery ensure the best patient outcomes; the location that the procedure is performed is less critical. Ambulatory surgery is a nonissue when things go well — the trick is being able to handle complications while mitigating risk.
LS: Right patient. Right procedure. Right time. Patient education. Meticulous surgical technique. Knowing your limits. Judicious adjuncts to narcotic analgesia (local anesthetic blocks and pumps, epidural steroids, etc).
VS: Stick to proper patient selection and make sure the staff is properly educated to make the surgery safe and efficient.
The opinions of Dr. Brian Gantwerker, Dr. Ray Gardocki, Dr. Lali Sekhon and Dr. Vladimir Sinkov are their own and not necessarily those of Stryker.