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12 Minimally Invasive vs. Open Spine Surgery P roviders today are focused on delivering high quality, low cost healthcare. In spine surgery, the debate over whether minimally invasive or open surgical techniques are more cost- effective depends on whether you're examining the initial episode of care or long-term costs and how you evaluate the economic impact of returning pa- tients to normal activity. "Some minimally invasive techniques require significant initial expenditures for imaging tech- nologies such as the O-arm, robotics, endoscopic equipment, etc.," says Brian S. Grossman, MD, of Southern California Orthopedic Institute in Van Nuys. "A hospital may need to generate a fair vol- ume of cases to justify the initial costs for these technologies. Other minimally invasive techniques can be performed at very little additional expense to the hospital. If patients are able to be discharged from the hospital sooner following MIS, there may actually be cost savings in that regard." The literature shows reductions in the length of stay after minimally invasive techniques when compared with open procedures. Patients also re- turn to work more quickly, limiting their produc- tivity and economic loss, and a lower risk of infec- tions and complications after minimally invasive techniques brings the cost down further. "I think you need to do a thorough cost analy- sis and outcomes analysis to really figure out true cost effectiveness," says Zachary A. Smith, MD, of Northwestern Memorial Hospital in Chicago. "Cost analyses show minimally invasive proce- dures cost about the same as open. The major advantage from the economic perspective is that patients return to work sooner and have less of a need for narcotics." The Spine Journal published an article in Novem- ber 2013 analyzing the perioperative costs asso- ciated with single-level minimally invasive and open transforaminal lumbar interbody fusion. The research showed hospital payments were higher for the open TLIF group than the mini- mally invasive group, each including 33 patients. Additional findings include: • Average surgical time was shorter for MIS (115.8 minutes) than open TLIF (186 min- utes) • Length of stay was shorter for MIS (2.3 days) than open TLIF (2.9 days) • Anesthesia time and EBL time was lower in the MIS group • VAS scores decreased for both groups, but were significantly lower for the MIS group • MIS had lower direct hospital costs ($19,512) than the open group ($23,550) • Implant costs were similar in both groups, but accounted for two-thirds of direct costs in the MIS group ($13,764) and half in the open group ($13,778) "When hospitals use pricing structures that rec- ognize all posterior spinal anchors as equal, they do not charge more for the set-up, access instru- ments or insertion devices necessary to place percutaneous instrumentation," says Alexander Vaccaro, MD, of Rothman Institute in Philadel- phia. "In this setting, surgery may be more cost effective if one is experienced than if procedures are done in an open fashion, as one would avoid the required time for opening the wound and per- forming an open dissection." The opportunity to perform these procedures in the ambulatory surgery center also presents cost- savings, as ASCs are reimbursed at a lower rate than hospitals and hospital outpatient depart- ments. "The MIS approach in ASCs helps otherwise healthy patients receive spine surgery outside of the hospital and minimizes their exposure to sicker patients," says Richard Kube, MD, Founder of Prairie Spine & Pain Institute in Peoria, Ill. "I think insurers are starting to wake up to the con- cept that this is safe to do in the ASC and will wel- come the cost savings." Medicare currently does not reimburse for spine surgery in the ASC setting, but some commercial payers in various regions of the country have been willing to contract with ASCs for spinal proce- dures. "In the long term, [minimally invasive spine sur- gery] may cost less as long as the complication and revision rates are low," says Paul Jeffords, MD, of Resurgens Orthopaedics based in Atlanta. "If the patients are able to leave the hospital quick- er, use less pain medication and return to work quicker, overall healthcare costs and the costs on society are reduced." n Cost-Effectiveness: How Do MIS & Open Spine Surgeries Compare? By Laura Miller racolumbar instrumentation, avoiding the need for open dissection neces- sary to expose the posterior elements," says Dr. Vaccaro. "Minimally invasive surgery may be beneficial at the superior end of the large posterior instru- mented construct to avoid soft tissue disruption which may predispose to proximal junctional breakdown." New technology could also close the gap between how comfortable surgeons are with minimally invasive versus open procedures. "There are a lot of promising technologies that are coming down the pipe- line," says Dr. Jeffords. "We have to be cautious and wait until there are proven outcomes for these studies before they are widely used. Also, at some point, as the size of the incision becomes smaller-and-smaller, the added benefit levels off as the risk increases. For instance, there may not be a clinical benefit to performing spinal fusion through a 1 cm incision as opposed to a 1 inch incision, but the risk of complication or failure may go up considerably." n Baxano Surgical, Inc. is a medical device company focused on designing, developing, and marketing minimally invasive products to treat degenerative conditions of the spine affecting the lumbar region. Baxano Surgical currently markets the AxiaLIF® family of products for single and two level lower lumbar fusion, the VEO® lateral access and interbody fusion system, iO-Flex®, a proprietary set of flexible instruments used by surgeons during spinal decompression procedures and the iO-Tome® instrument, which rapidly and precisely removes bone, specifically the facet joints, which is commonly performed in spinal fusion procedures. Baxano Surgical was founded in May 2000 and is headquartered in Raleigh, North Carolina. For more information, visit www.baxanosurgical.com.