Eight spine and neurosurgeons provide their insight into key patient evaluation considerations when performing outpatient spinal fusion.
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. We invite all spine surgeon and specialist responses.
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Note: The following responses were edited for length and clarity.
Question: What are your key patient evaluation considerations when performing outpatient spinal fusion?
Vladimir Sinkov, MD. New Hampshire Orthopaedic Center (Nashua): Outpatient spinal fusion, when done in an appropriate setting on a properly selected patient, can be a safe, effective, and very cost efficient way to perform spinal fusion. However, this operation can have significant complications and side effects. The patients need to be healthy enough to tolerate the procedure, be able to handle potential complications, and motivated and informed enough to be able to be discharged safely the same day or after a 23-hour stay.
When performing outpatient fusions, I generally exclude patients with multiple medical comorbidities, significant preoperative disability, sleep apnea, morbid obesity, high risk of blood clot formation and chronic opioid dependence. These patients are more likely to require a longer stay and more intensive postoperative care and rehabilitation. Such patients are better suited to have their surgery done at a hospital. I also make sure that patients being scheduled for outpatient fusions are well-informed about their postoperative care and have a good support system at home.
Grant Shifflett, MD. Hoag Orthopedic Institute (Irvine, Calif.): The first step to transitioning your surgical practice to an outpatient environment is identifying good surgical candidates. This should of course start narrow and grow with increasing comfortability. Early on the patient population should primarily be young, not overweight, a non-smoker, with minimal comorbidities who need simple one level operations with which you feel exceedingly comfortable. However, with time and experience, I believe it is as much about patient education, expectation and surgical technique as it is about patient selection. Ultimately, the roof over your head when doing surgery doesn’t inherently change the patients ability to undergo surgery safely; your ability to be a minimally invasive, safe, and predictable surgeon, provide reproducible anesthesia, and having access to a team of perioperative nurses that feel comfortable aggressively recovering a postoperative patient make outpatient surgery successful.
Raymond Gardocki, MD. Campbell Clinic Orthopedics (Memphis, Tenn.): Patient health and airway are the two primary factors less than chronological age. We can treat most one- and two-level lumbar pathology as an outpatient, be it discectomy, decompression or fusion using minimally invasive approaches.
James Chappuis, MD. Spine Center Atlanta: Prior medical history is probably the most important consideration, especially conditions that would negate the surgery being completed in an outpatient setting. This is also where you must have a good working relationship with your anesthesiologist. This is why we have a dedicated in-house anesthesiologist, Dr. Ngan Pham, who evaluates the patient with me. If there are concerning medical problems, I would recommend a preoperative clearance from primary care or internal medicine. If there's still a problem, then that patient should not be performed on in an outpatient setting but should be operated on inpatient or the concerns may just be a contra indication in general to surgery.
Brian R. Gantwerker, MD. Craniospinal Center of Los Angeles: The patient's health status and outstanding medical problems are the first consideration. Use of a risk stratification inventory like the ACS offers can be a good guide for seeing the patient's risk probability. The gut check works as well and if your first consideration is to do the case inpatient, then that is the best bet.
Scott Russo, MD. Orthopaedic Associates of Michigan (Grand Rapids): The preoperative health of the patient and the support team in place at home to care for them.
Issada Thongtrangan, MD. Microspine (Phoenix): Outpatient spine surgery has been a hot topic in the past several years. I always use the shared decision making between me, the patient and their family members. The patient and their family must understand the nature of surgery and the outpatient postoperative course. Patients and their family member must understand the concept of early ambulation, minimizing opiates medications, utilizing multimodal pain management. They also must understand and be able to notice signs and symptoms of early postoperative complications related to their surgery. In my practice, our team will call and follow up with the patient and their family that night and the next 2-3 days to ensure they do not have any complications and to coach them through their postoperative courses.
Another important factor is their health. I usually review their medical problems, medications, BMI, comorbidities and sleep apnea. For example, there are several studies demonstrating the high complications in high BMI patients, patients with an ASA physical status above two, patients with poor controlled diabetes etc. Age is not an absolute contraindication for outpatient surgery for me but rather the patient's physiologic age and health. Additionally, my practice has a multidisciplinary team involving surgeons, anesthesiologists and OR nurses to review the challenging cases and make the final decision as a team, so the surgeon has accountability and we ensure patients are safe.
Mark Mikhael, MD. NorthShore Orthopaedic Institute and Illinois Bone & Joint Institute (Chicago & Glenview, Ill.): Two main considerations for patients who might be good candidates for outpatient spinal fusion are motivation and good health. Patients have to be onboard with a plan to go home the same day as surgery and care for themselves. The patient also has to be healthy enough to tolerate the procedure and be mobile soon after. Outpatient spinal fusion is not for everyone. If the patient is at high-risk for complications, staying at the hospital for a night or two is a better option, so proper post-surgery monitoring can take place. Patient safety is paramount. The trend is to encourage outpatient spinal fusion, but it can be unsafe. Patients need to fit the criteria for the procedure in an outpatient setting for it to be successful.