Becker's Spine Review

42 ASC Minimally invasive spine cases find success in ASCs, but complex surgeries slow to transition By Alan Condon M any minimally invasive spine pro- cedures such as cervical disc re- placement and microdiscectomies are performed at ASCs, but a significant portion of complex cases such as multilevel fusions and scoliosis are still being done in the hospital setting. Four spine surgeons discussed the barriers stunting the transition of complex spine sur- geries to the ASC setting and what changes could accelerate the migration of these cases. Editor's note: Responses were lightly edited for clarity and length. Question: Why has the pace of spine surgery migration to ASCs not kept up with that of joint replacement in recent years? Wesley Bronson, MD. Mount Sinai Health System (New York City): Ample research has demonstrated the safety of performing outpatient spine surgery in ASCs, especially for common procedures such as microd- iscectomy, laminectomy, [anterior cervical discectomy and fusion] or cervical disc re- placement, and even some more complex cervical and lumbar fusion procedures. rough a combination of careful patient selection, preoperative planning and peri- operative techniques, complications are low and the need for transfer to a formal hospital are low. Nonetheless, many surgeons are re- luctant to transition these patients into ASCs due to the potential for complications that may be difficult to manage in an ASC such as hematoma, airway compromise, [cerebrospi- nal fluid leak] leak or intractable pain. I be- lieve as more research is published demon- strating the safety profile of these procedures in the ASC setting, more surgeons will feel comfortable transitioning more procedures out of the hospital setting. Ehsan Jazini, MD. Virginia Spine Institute (Reston): Spine surgery is much more het- erogeneous compared to joint surgery. e spine involves multiple joints and levels with a higher degree of complexity, especially for multilevel procedures of the cervical or lum- bar spine. e smaller minimally invasive procedures such as endoscopic, microdis- cectomy, and one or two levels cervical disc replacement fusion are being pulled to ASCs but the larger multilevel fusions and scoliosis surgeries are difficult to transition to ASCs due need for expensive technologies as well as the need of more intensive aercare. As spine surgery is becoming less invasive, using highly specialized training combined with enabling technologies, this will gradu- ally change. At Virginia Spine Institute, we have also tailored and developed enhanced recovery protocols, known as the enhanced recovery aer surgery program, that has led to faster recovery for patients, especially for more complex surgeries. Philip Schneider, MD. e Centers for Advanced Orthopaedics (Bethesda, Md.): Spine surgery is migrating at a steady pace to the outpatient setting. ere appears to be a differential because spine surgeries such as ACDF and lumbar discectomies moved to the ASC setting earlier. Total joint proce- dures hadn't migrated until more recently, with advancements in direct anterior and other techniques. In spine surgery, the big shi will occur when we start performing more lumbar fusions — which require more equipment — in ASCs. Once we get past that hurdle, we'll see a faster migration of spine surgery to ASCs. Brian Gantwerker, MD. e Craniospinal Center of Los Angeles: Spine surgery is a variable, highly individualized surgery. e results are, unfortunately, not as reproduc- ible as joint replacement, even in the best hands. e acuity of the cases as well as pa- tient factors have driven surgeries out of the ASC and back to the hospital in some cases. Lastly, a downtrend in reimbursement and the reward of the stick rather than the car- rot when your organization has done a good job has discouraged them from taking these cases outpatient when medically feasible. n "In spine surgery, the big shi will occur when we start performing more lumbar fusions — which require more equipment — in ASCs." - Philip Schneider, MD. The Centers for Advanced Orthopaedics

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