Becker's Spine Review

8 EXECUTIVE BRIEFING SPONSORED BY Moving spine surgery to the ASC: 4 surgeons' advice Spine surgery still has room to grow in the outpatient setting. As minimally invasive techniques and navigation technologies evolve, some spine surgeons have considered taking the leap into the ASC setting. Four spine surgeons shared their insights on outpatient spine surgery and implementing it in the ASC: • Brian Gantwerker, MD. The Craniospinal Center of Los Angeles • Ray Gardocki, MD. Vanderbilt Spine (Nashville, Tenn.) • Lali Sekhon, MD, PhD. Reno (Nev.) Orthopedic Center • Vladimir Sinkov, MD. Sinkov Spine (Las Vegas) Note: Responses were lightly edited for clarity. Question: What spine procedures do you expect will become more prominent in the ASC setting over the next three years? Dr. Brian Gantwerker: Over the next three years or so, we will see a steady increase in procedures such as lateral interbody fusion and 1- and 2-level cervical and lumbar arthroplasty. There is still a push to have patients have surgery in a safe setting with the ability to observe them for 23 hours and allow them to go home after. Endoscopic surgery is also an interesting field, but there is some significant start-up cost associated with it, and no unique CPT code associated with it as of now. There is not a bigger reimbursement delta to offset the risk of acquiring the equipment and not doing enough cases to get the proper ROI. Dr. Ray Gardocki: I believe there will be more ASC-based instrumented lumbar fusion performed as well as the full gamut of endoscopic spine procedures. Ambulatory endoscopic spine surgery can be used to address cervical foraminal stenosis (from disc or osteophyte), thoracic disc herniations (soft and calcified), lumbar discectomies, decompressions and even interbody fusions. As the ratio of endoscopic interbody fusions increases, many of these procedures will migrate to the ASC. Dr. Lali Sekhon: Anterior cervical discectomy and fusions, simple decompressions — both cervical and lumbar — and spinal cord stimulators all get done in ASCs from a spine perspective. The next goal is lumbar fusions at 1 and 2 levels performed from any approach. Just like our orthopedic colleagues, lumbar fusions will become a 23-hour or same-day surgery. Cheaper outpatient spinal navigation will facilitate this. Dr. Vladimir Sinkov: I believe lumbar decompressions, cervical fusion and disc replacements, and (to a lesser degree) minimally invasive lumbar fusions will become more prominent. Q: What are your tips for migrating these procedures to the ASC? What technologies or case approaches do you recommend in safely and effectively performing these cases in outpatient settings? BG: Patient selection remains key in doing ASC cases. It is important if the patient falls into a higher risk echelon that they be recommended for surgery in the inpatient setting. Additional tips to get patients to the ASC is hiring and maintaining properly trained staff in the OR. Selecting for very experienced staff at all phases of care will pay off in great dividends. Technology is a double-edged sword. On the one hand it makes some surgeries deceptively simple, but in the wrong hands, it can lull some of the untrained into a false sense of security. There are a plethora of technologies on the market that are not necessarily good for patients and are being used somewhat irresponsibly and in potentially inappropriate cases. I would caution ASC managers and administrators to look at these with a somewhat jaundiced eye and use caution when dealing with those who seem to be selling a bill of goods RG: Minimally invasive and endoscopic techniques which minimize pain and morbidity while still achieving the fundamental operative goals are the primary tools to migrate cases to the ASC. Regional blocks and neuraxial anesthesia can also be helpful, especially in elderly patients or those with increased co-morbidities.

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