Sanjeev J. Suratwala, MD, an orthopedic spine surgeon at North Shore-LIJ Health System and assistant professor in the department of orthopedic surgery at Hofstra NS LIJ School of Medicine, discusses outpatient spine surgery and where the driving trends are heading in the future.
Q: What are the most important innovations in outpatient spine today?
Dr. Sanjeev J. Suratwala: The way we approach managing pain and disability after surgery has seen some innovations. When you are trying to perform any type of surgical procedure and make it outpatient instead of inpatient, you want to focus on minimizing the patient's pain. There are new percutaneous surgical techniques, minimally invasive surgical techniques as well as robotic technology and new devices that require smaller incisions so patients don't have as much pain or disability. The recently popularized the lateral approach to spine surgery, which also minimizes dissection and tissue damage for interbody fusions.
From an even bigger picture standpoint, we are looking at whether we need to perform traditional spine surgery at all in the first place. Instead of performing laminectomies we can consider implants like the coflex device that decompress while minimizing morbidity. Traditional spinal fusions could be replaced with motion preserving techniques.
You can transition a traditionally inpatient procedure into the outpatient setting.
Q: What new technologies or devices could make an impact on outpatient spine in the future?
SS: The interspinous devices such as X-stop and now coflex are being researched and looked at to minimize the traditional laminectomy approach. The disc replacement implants especially in the cervical spine are approved in the United States and are seeing increased usage. That's something that can be done as an outpatient procedure because you are minimizing restrictions afterward.
The goal here is to keep patients mobile. The early research on disc regeneration technology is promising. If we can regenerate the disc then we don't have to perform a fusion or disc replacement. That could change procedures tremendously and likely remain in the outpatient setting.
Robotic surgery has also made it technically possible to do more challenging cases with less invasive procedures. When you minimize the incision and the muscle trauma, you can significantly reduce post-procedure pain and disability which is often the primary reason for prolonged hospitalizations. The targeted robotic approaches are one way to convert the traditional inpatient procedures to outpatient surgeries.
Q: How can spine surgeons optimize their outpatient procedures? What do they need to know about transitioning cases from inpatient to outpatient?
SS: It's very important to have a good team approach when performing complex surgeries as an outpatient. Good outcomes start with good patient education. When a patient comes into your office, the assumption is he or she will be hospitalized for a few days after their spinal surgery. It takes some effort to convince the patient that the surgery can be done in an ambulatory setting. Patients and staff should be on the same page and know they're undergoing outpatient surgery. The education of your staff is also critical here so that there are no mixed messages. The clinical team should emphasize adequate pain management and early ambulation.
Then I begin to think about patient selection. Book patients conservatively for the outpatient ASC when first transitioning cases. There is a learning curve to get everyone transitioned, but it's certainly feasible for discectomies, decompressions performed with implants and anterior cervical spine surgeries. Percutaneous fusions can be challenging to perform in an ambulatory setting but with the right patient and the right team can be performed.
The other essential component is pain management. If you have adequate pain management then patients are more comfortable and willing to go home. If patients are in significant pain, they won't want to go home. Develop good protocols for pain management at the center.
Q: From your perspective, is it financially feasible to perform spine cases in the ASC?
SS: With the reimbursement declining and expectations that surgery should cost less, there is more pressure on healthcare providers and facilities to get patients home sooner. I think the push from the financial standpoint will drive innovation and change. People are critically looking at whether a person needs a certain procedure like spinal fusion because there are alternatives.
Costs and finances matter in the transition to outpatient procedures. In this economy, a lot of spinal care is being driven toward ASCs because their core function is getting patients home sooner. But one caveat is this trend shouldn't compromise patient safety. Just because you can save on costs for outpatient procedures doesn't mean every case should go there. Make sure you're treating the patient appropriately for their condition.