Becker's Spine Review

7 SPINE Lumbar spinal fusion reoperation rates: Does technique matter? By Carly Behm S ingle-level lumbar spinal fusions had similar reoperation rates between anterolateral and posterior surgical techniques, according to a study in the September 1 issue of Spine. Researchers looked at data for patients who had single-level anterior lumbar interbody fusion/lateral lumbar interbody fusion or transforaminal lumbar interbody fusion/posterior lumbar interbody fusion with same-day, single-level posterior instrumentation. Patients were followed for at least two years, and the ALIF/TLIF and TLIF/PLIF cohorts were matched 1:1 by factors age, sex, smoking status, Elixhauser-comorbidity index and diabetes. Each cohort had 14,070 patients after matching, and all-cause subsequent lumbar operations were nearly identical at the five-year follow-up (9.4% for ALIF/ LLIF and 9.5% for TLIF/PLIF). But within 90 days of surgery, the TLFI/PLIF cohort had more infections and dural injuries. The study concluded, "As utilized in real-world clinical practice, single-level anterolateral versus posterior approaches for interbody fusion have no effect on long-term reoperation rates." n How ASCs can unlock profits with outpatient spine migration By Francesca Mathewes T he demand for outpatient spine surgery is growing as technological developments make high-acuity procedures more feasible in the ASC setting. Here are things for ASCs to consider as they expand into the outpatient spine market: 1) Look to lumbar/thoracic fusion procedures. These were among the top procedures that shifted to the outpatient market in 2023, according to the 2023 Impact of Change Forecast report published by SG2, a Vizient company and healthcare consulting group. According to the report, 17% of spinal decompression or laminectomy procedures will be performed in ASCs by 2033. 2) Focus on total joint replacements. In March, physicians told Becker's that total joint procedures were key to the future of ASC growth. "ASCs are demonstrating that quality care for total joints can be achieved while ensuring patient safety and satisfaction are at the forefront of their experience," Joyce White, RN and facility administrator of Cypress Surgery Center in Wichita, Kan., told Becker's. Total shoulder replacement was also added to the CMS's list of ASC-covered procedures. 3) Enhance precision, accuracy and efficiency are key. As the demand for outpatient spine care continues to grow, implementing robotics and intraoperative imaging can allow surgeons in the ASC setting to provide high-quality care for increasingly complex cases. 4) Keep safety at the forefront of development is vital. It's important for a facility's safety to match the increasingly high-acuity procedures taking place in ASCs. The SG2 report highlights several technologies that minimally invasive spine surgery by giving surgeons precise bony anatomy visualization. Implementing digital navigation technologies is another way that ASCs can optimize their efficiency without sacrificing safety. 5) Team up with spine companies. Many spine companies are "emphasizing collaboration" with ASCs and surgeons in order to create products more specifically tailored to their needs, according to the report. n Tiffany Perry, MD, a neurosurgeon at Los Angeles-based Cedars- Sinai and the study's lead author, explained how screw sizes could affect the outcomes. "e L2 and L3 pedicles are usually smaller," Dr. Perry told Becker's. "ey're narrower than the L4 and L5 [pedicles], so we have to pay a lot more attention to the start point and trajectory of the screws at L2 and L3 because you have less of a window that you're working in. You have a narrower pedicle and for L4 and L5, the pedicles tend to be wider. As far as the trajectory of the actual pedicles, they tend to be angled in or medialized a little bit more, which makes it a little easier to have less sky as you're doing robotic approaches." Another finding from the study showed percuteneous robot-assisted and CT navigated approaches showed fewer facet violations than open approaches. "With the percutaneous [approach], you've got all of your surrounding tissues that are helping you to maintain your trajectory … and when you're doing open surgery you have all of the so tissues," Dr. Perry said. "If you have a robotic arm that's coming down through an open incision, you have to have all of the muscle, all the skin and all the so tissues dissected away. ere's nothing that could move your robotic arm or could move your navigation away from that tissue. You have to have a longer incision when you're doing open robotic surgery." Dr. Perry said another key takeaway from the study is the reminder that no spine robot or spine navigation is perfect without human expertise. "Ultimately, it goes to show us that no matter how great the technology or how great the robot or how advanced that placement is, there still can be mistakes that are made," she said. "You can have the perfect trajectory and the perfect screw placement, but if that surgeon places that screw in too deeply, you have to fix the violation. No matter how perfect our technology is, there's always human error. So I think this [study] actually does point that out more than anything." n

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