Becker's Spine Review

17 EXECUTIVE BRIEFING SPONSORED BY The future of spine in ASCs O utpatient spine is on track to becoming the new normal, and ASCs are on the forefront of the transition. More than 190 ASCs in the U.S. now offer minimally invasive spine surgery, a significant increase in the last decade. Outpatient surgery migration has been spurred by recent advances in surgical techniques, anesthesia and postoperative rehab. These developments have resulted in lower-cost, shorter procedures with less blood loss and fewer complications, allowing surgeons to send patients home safely within 24 hours of surgery. Three spine leaders — Nitin Khanna, MD, of Spine Care Specialists in Munster, Ind.; Richard Kube, MD, of Prairie Spine & Pain Institute in Peoria, Ill.; and Richard Jeffords, MD, of Resurgens Orthopaedics — joined Becker's ASC Review to discuss the migration of spine procedures to ASCs, and what they predict in the coming years. Editor's note: These responses were edited lightly for brevity and clarity. Question: Where do you see the future of spine in ASCs headed? Dr. Nitin Khanna: There is only one direction for ASCs — up. Convenience, cost and quality are the elusive ingredients for healthcare, and all [are] captured with the ASC physician- ownership model. Hospital systems will need to adopt this strategy in order to remain market-competitive and grow. Dr. Paul Jeffords: Already over the last five to 10 years, we've seen a migration of spine cases from the hospital to the surgery center. I think that as time goes on, what we'll see is more and more complex cases being transferred as surgeons and anesthesiologists and nursing staff get more comfortable managing those patients on an outpatient basis. Dr. Richard Kube: Clinically, most things are feasible to perform in an ambulatory surgical facility. Yet, we see Medicare shifting different codes back out of ambulatory settings. If and when the self-funded, self-insured market wakes up to the money that they're blowing needlessly, I think we will see enormous volumes of cases starting to move in the ambulatory setting. Until then, I think the hospital industry and the insurance industry that profits by keeping those cases in their current environment will continue to do what they can to make sure the status quo remains. Q: What spine procedures and technologies are moving from the hospital to the ASC? Dr. Khanna: We are seeing previously unheard-of routine lumbar fusions now performed in an outpatient setting. Disc replacement really embodies the true advances that we have made in spine during my 20 years of private practice. We can now decompress the neural elements and restore motion with the patient at home within two to three hours and off pain medication within two to three days. It is remarkable how far we have come. Dr. Jeffords: From a technology standpoint, obviously, the minimally invasive implant systems have allowed us to do these cases on these patients in an outpatient setting. The minimally invasive nature of these cases leads to less pain, quicker recovery and less blood loss. It's a better experience for the patient. Additionally, image guidance and navigation — as surgeons are taking these more complex minimally invasive lumbar fusions to the ASC, the navigation and imaging will naturally migrate with those cases. Dr. Kube: Anesthesia techniques have improved, surgical techniques have improved and patient education has improved to the point that the vast majority of spine procedures can be done in an ambulatory center. We do those regularly, especially when you have an overnight capacity. If you don't have an overnight capability, that does change things quite a bit. You do have to worry about swelling, you do have to worry about some different aspects that would limit significantly the types of cervical spine cases I would do if I didn't have the ability to have somebody overnight. I know different people try to look for technology to get there, but I think most of that technology is already here. There are things that will continue to make surgeons' lives easier and make it more feasible to perform a variety of things. Those will just improve what's already there, whether it's imaging techniques or navigational techniques. Those will just continue to improve things. "Anesthesia techniques have improved, surgical techniques have improved and patient education has improved to the point that the vast majority of spine procedures can be done in an ambulatory center." Richard Kube, MD, of Prairie Spine & Pain Institute in Peoria, Ill.

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