Complex spine surgery can work in ASCs. Here are the steps to get there

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More spine surgeries are migrating to ASCs, and the outpatient setting has been ideal for minimally invasive procedures. But work still needs to be done to optimize complex spine cases for ASCs. 

Six spine surgeons discuss the factors that will bring more complex spine surgeries to the ASC.

Note: Responses were edited for clarity.

Question: What's needed to perform more complex spine surgeries in the ASC safely?

Brian Fiani, DO. Mendelson Kornblum Orthopedic & Spine Specialists (West Bloomfield, Mich.): To push more complex spine surgeries into the ASC sooner, it is important to have a strong focus on patient safety and outcomes, as well as ensuring that the ASC has the necessary equipment and resources to handle such procedures. Additionally, building strong relationships with referring physicians and payers can help in gaining support for moving complex spine surgeries into the ASC setting. Training and development programs for staff members to ensure they are able to handle complex cases efficiently and effectively is also key. Staying informed on the latest advances in surgical technology and techniques can help in the case for performing complex spine surgeries in an ASC setting. We have purchased two Mazor robots for our ASC which allow us to move in this direction to offer our patients the latest technologies and the safest surgeries.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: More complex surgeries done in ASC setting must be done gradually. More ASCs will need to get special exemptions to hold patients greater than 23 hours. Some ASCs should stick to the simple, safer, and better margin surgeries. For those wanting to push the envelope, I recommend doing a careful safety analysis with a multidisciplinary team of anesthesiologists, pain physicians, internal medicine, nursing, and surgery staff to decide what is safe and feasible. Just because you can do a surgery in an ASC setting does not mean you should. Any transformation into a higher acuity center should take place gradually, with very careful consideration of each patient case and its appropriateness for the ASC setting.

Arya Shamie, MD. UCLA Health: I believe that several key factors must align to facilitate the transition of more complex spine surgeries into ASCs sooner rather than later. First, advancements in surgical techniques and technology have significantly enhanced the feasibility of performing complex spine procedures in outpatient settings. Minimally invasive approaches, improved instrumentation, and enhanced imaging modalities have reduced surgical invasiveness and postoperative recovery times, making ASCs increasingly viable for complex cases.

Second, comprehensive preoperative assessment and patient selection are imperative. Rigorous evaluation of patient comorbidities, surgical risk factors and social support systems is essential to identify candidates suitable for outpatient complex spine surgery. Collaboration among multidisciplinary teams comprising spine surgeons, anesthesiologists, and rehabilitation/pain specialists is crucial to optimize patient selection and perioperative care pathways.

Regulatory and reimbursement frameworks also need to adapt to accommodate the shift towards performing complex spine surgeries in ASCs. Streamlined accreditation processes, standardized protocols, and adequate reimbursement mechanisms are essential to incentivize surgeons and healthcare facilities to embrace this transition while maintaining patient safety and quality outcomes.

Patient education and empowerment play a pivotal role in fostering acceptance and confidence in outpatient complex spine surgery. Providing patients with comprehensive information regarding the benefits, risks and expectations associated with ASC-based procedures can alleviate concerns and facilitate informed decision-making.

The successful integration of complex spine surgeries into ASCs requires a concerted effort from stakeholders across the healthcare continuum. By leveraging technological innovations, optimizing patient selection criteria, adapting regulatory frameworks, and fostering patient-centered care models, we can propel the evolution of spine surgery towards more efficient, cost-effective, and patient-centric outpatient settings.

William Taylor, MD. University of California San Diego Health: I'm concerned that pushing surgeries into the ASC somehow indicates that this is an outcome that is somehow directed towards improvement, inpatient care. My initial responses that continued penetration of minimally invasive surgery should be a driving force behind moving people to the ASC. Unfortunately, the growth of this, except for isolated procedure related surgery interventions, has not expanded. I also believe that continued multidisciplinary treatment of patients, which includes ERAS protocols, anesthesia, responses, and alternative viable options for short term patient care, should improve this.

Vijay Yanamadala, MD. Hartford (Conn.) HealthCare: The use of ASC for spine surgery has increased tremendously in recent years. In my practice, I am using the ASC largely for decompressive surgeries such as single level and multilevel laminectomies and discectomies. I do see getting more complex surgeries including anterior cervical discectomies and fusions and lateral and posterior lumbar fusions to the ASC setting soon. Safe use of the ASC setting for complex surgery requires us to have:

1) Clear patient expectations that they will return home. 

2) Clear protocols for emergency care and processes for inpatient admission should it become necessary. This is perhaps the most important part of the process. There should never be a surprise when it comes to surgery. However, being prepared for the unexpected is essential as a surgeon or as an anesthesiologist at an ASC. 

3) Standardized algorithms to assess who will be a good candidate (patients with limited comorbidities, low ASA classification).

4) Home care paradigms including nursing, physical therapy, wound care that may not be necessary for simpler surgeries but will be increasingly necessary for more complex surgeries. 

5) A team that can help translate complex surgeries from the hospital to the ASC. If possible, having the same team for the first several cases for a new procedure in the ASC can help ease the transition and ensure efficiency.

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): The answer to this paradoxical question is the level of care for acuity-based diagnosis and the comparable specialty of deliverable care these institutions do not provide. Most surgery centers are not equipped with complex post-operative care from a physician nor advanced nursing standpoint, (ICU and step-down units). Not having this level of care should deter most presupposing surgeons from performing complex surgeries based on safety issues and true patient-centric concerns. The other ramp up would include multiplex anesthesia services, with both capability and willingness to manage these complex patients intra/post operative.

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