Becker's ASC Review

24 ASC Management Seven spine surgeons discuss outpatient spine surgery and where it's headed in the future. Q: What are the most important innovations in outpatient spine today? Neel Anand, MD, Clinical Professor of Orthope- dic Surgery and Director of Spine Trauma, Ce- dars Sinai Spine Center, Los Angeles: Minimally invasive spine surgery is one of the most impor- tant innovation in outpatient spine today. New techniques have really changed what we can do in surgery especially with techniques that enable less blood loss and dissection through less invasive procedures. This makes it overall easier to perform spinal surgery in the outpatient setting. Neil Badlani, MD, North American Spine, Hous- ton: Tubular retractor systems with specialized in- struments and high powered microscopes or endo- scopes allow procedures to be done in this fashion. Better instrumentation including more percutaneous instrumentation and standalone interbody cages are important advancements. Alternative approaches to the spine such as the lateral approach or mini-open anterior or oblique approaches allow access to the spine without significant disruption of muscle. Todd Alamin, MD, Stanford Medicine, Redwood City, Calif.: Better operative microscopes that al- low for surgical goals to be accomplished through less disruptive exposures [with] better lighting, vi- sualization, magnification. Newer, longer acting lo- cal anesthetics promise better pain control for the early postoperative period, like liposhpere-encap- sulated bupivacaine. Sanjeev J. Suratwala, MD, North Shore-LIJ Health System, New York: There are new percutaneous surgical techniques, minimally invasive surgical techniques as well as robotic technology and new devices that require smaller incisions so patients don't have as much pain or disability. The recently popularized lateral approach to spine surgery also minimizes dissection and tissue damage for inter- body fusions. From an even bigger picture standpoint, we are looking at whether we need to perform traditional spine surgery at all in the first place. Instead of performing laminectomies we can consider implants like the coflex device that decompress while mini- mizing morbidity. Traditional spinal fusions could be replaced with motion preserving techniques. Q: What new technologies or devices could make an impact on outpatient spine in the future? NB: Spine surgery is still a frontier with constantly advancing technology. Robotic spine surgery will likely continue to become more common and make a bigger impact on less invasive spine surgery. We can expect continued advancements in instrumentation and spinal devices. New technologies that help minimize blood loss during spine surgery such as the use of tranexamic acid or transcollation technology will make an impact. Stephen Hochschuler, MD, Co-Founder, Texas Back Institute, Plano: Everyone is looking to de- crease costs for spine procedures, and ASCs receive lower reimbursement than hospital outpatient procedures. With image intensification such as the O-arm and robotics, people are comfortable doing quality outpatient procedures because they are go- ing to be more percutaneous. The portable CT scan makes this a different world. Surgeons are getting used to it and it's becoming the paradigm of care. SS: The interspinous devices such as X-stop and now coflex are being re- searched and looked at to minimize the traditional laminectomy approach. The disc replacement implants especially in the cervical spine are approved in the United States and are seeing increased usage. That's something that can be done as an outpatient procedure because you are minimizing restrictions afterward. The goal here is to keep patients mobile. The early research on disc regen- eration technology is promising. If we can regenerate the disc then we don't have to perform a fusion or disc replacement. That could change procedures tremendously and likely remain in the outpatient setting. TA: Less disruptive fusion techniques and better methods and techniques for endoscopic decompression. Current options probably are too difficult for broad use and further have structural issues associated with them. Q: There are still people who are skeptical of doing any spine procedures in the outpatient setting. Will anything change their minds? Gowriharan Thaiyananthan, MD, Founder, BA- SIC Spine, Newport Beach, Calif.: The key is to provide skeptics with information and data. Sur- gical procedures done in the outpatient surgical setting are producing better results for the patient. The infection rates are lower, postoperative com- plications rates are lower (because the procedures performed are less risky) and patient satisfaction is higher. Also, overall costs are much lower. Pro- viding patients with the same information that we use practice evidence-based medicine may help people who are skeptical of outpatient spine procedures see the paradigm shift which is occurring. Q: How can spine surgeons optimize their outpatient proce- dures? NB: Patient education and patient selection is the most important aspect of this. Patients should be willing and motivated to have an outpatient procedure and interested in a quicker recovery. When transitioning sur- gery from the inpatient to the outpatient setting, it is prudent to have a stepwise approach and start with more straightforward procedures in healthier patients first and expand indications later. It is safe to have the option to admit to an inpatient facility if necessary particularly early on in the process. NA: Surgeons must make sure they have a really good anesthesiologist. Make sure all the equipment is where it should be and you have everything you need at the outpatient center. If something were to go wrong, you also need a plan. If the patient loses more blood than expected, you have to be able to take care of that patient. Outpatient Spine Surgery Innovation: Key Concepts for Adding Cases By Laura Dyrda

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