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85 ORTHOPEDICS The next 3 years in spine: What will gain ground on fusion? By Laura Dyrda O utpatient surgery and fewer fusions are likely the future of spine surgery, according to Peter Derman, MD, a spine surgeon with Texas Back Institute in Plano. Question: How do you see spine changing in the next three years? Dr. Peter Derman: There is going to be more outpatient surgery. This was already a trend toward outpatient, but COVID-19 really brought this to the forefront, especially because hospitals were overwhelmed, and patients didn't want to be in the hospital. There has been an even greater push toward doing surgeries that were traditionally consid- ered inpatient stays on an outpatient basis. Part of that does fold into minimally invasive surgery because you can't send someone home the day of surgery if they had a big cut. I think less fusion is something we're seeing, and that will continue. We'll look back in 30 years and say, 'Look how barbaric the things we were doing 30 years ago were. We were fusing people.' I came to spine surgery through orthopedics, and when you have knee or hip arthritis they used to fuse your joint. But if you went to a hip surgeon now with hip arthritis and they planned to do a fusion on you, you'd run the other way, albeit slowly because you have hip arthritis. I think we're going to view it similarly in the future in spine. We'll realize we were fusing patients, and that's not a natural way for the spine to move, or not move. Motion preservation, whether through disc replacement, or per- haps in many cases, by decompressions that are minimal- ly invasive and don't further destabilize the spine. One of the cool things about endoscopic procedures is they've allowed me to do decompressions on many different patients who would have traditionally obtained a fusion. You can sometimes decompress transforaminally even to the center of the canal without destabilizing the segment in any way. As our disc replacement devices improve, and our ability to decompress without destabilizing improves, we're going to see more and more of a trend away from fusion as a treatment paradigm. n multiple medical problems and/or require complex reconstructive spine procedures will continue to receive care in hospital settings. e keys to successfully migrating cases to ASCs are: 1) Refining surgical technique to improve efficiency, ensure safety, reduce cost and provide reproducible results. 2) Negotiating contracts that are favorable to the ASC. 3) Providing care and personalized attention to detail that cannot be found in hospital- based settings. Richard Kube, MD. Prairie Spine (Peoria, Ill.): At this time, 100 percent of the cases I perform are done in an ambulatory setting. I have not used a hospital for spine surgery since September 2014. We are very proficient at performing several procedures for cervical, thoracic and lumbar conditions. One- and two-level fusions and disc replacements are commonplace in our facility, as are decom- pressions and motion-preserving techniques. Since we have the ability to keep patients overnight, we have also done three- and four-level cervical and lumber cases as well, though certainly with less frequency. As I do not treat major deformity or tumor, there is really nothing I need to do that is not already being done in outpatient facilities. Todd Lanman, MD. Lanman Spinal Neurosurgery (Beverly Hills, Calif.): For several years now, we have been performing one- and two-level artificial disc replace- ments for both the cervical and lumbar spine at our surgery center. Outcomes have been consistently positive, and patients have had no issues postoperatively. We increased our surgical capabilities for multilevel disc replacements with a hybrid procedure that involves a fusion at one level and artificial discs usually above the fusion. Multilevel disc replacement procedures are oen two- and three-level. Sometimes we perform four-level disc replacements. Artificial disc replacement surgery is done anteriorly. For lumbar procedures, we go through the abdomen; therefore, the patient experiences more operative time and recovery. We see less operative time and recovery with cervical because, although anterior, the neck is far simpler to manage than the abdomen. Most of our patients go home a few hours aer their procedure. One- and two-level disc replace- ment patients can oen resume low-impact activities within weeks of the procedure. ree- and four-level procedures have longer operative time and require more recovery time. However, patients are oen strong enough to leave the same day to make a full recovery at home within two or three months. Christian Zimmerman, MD. Saint Alphon- sus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): e transformation- al change of 'discharge planning' associated with COVID-19 has surprisingly rearranged larger health system surgery discharges into a surgery center culture. For better or worse, this patient- and health system-driven mind- set, currently and possibly going forward, strives to safely liberate post-surgical patients upon systemic clearance. Yet the complex procedural patient, [body mass index-laden] and multisystem involved remain a constant challenge. Legal and community issues aside, the American Society of Anesthesiologists physical status classification system designees continue to hamper more complex cases from being considered in ASCs. is, too, may change as comprehensive health systems engage all patient populations. Lane Spero, MD. Litchfield Hills Orthopedic Associates (Torrington, Conn.): I currently perform a number of lumbar and cervical disc procedures at our ASC. is year, I would like to start migrating several spinal fusion pro- cedures, including anterior lateral interbody fusion, XLIF (extreme lateral interbody fusion) and open TLIF, to our ASC. Issada ongtrangan, MD. Microspine (Scottsdale, Ariz.): I am looking forward to incorporating the endoscopic approach and navigation in fusion surgery into the outpatient setting. I began performing full endoscopic or endoscopic-assisted lumbar fusions in the ASC setting last year in a se- lect group of patients, and the outcomes are comparable, if not better, than the minimally invasive tubular-based approach. Patient safety and patient selection are the keys. n