Many minimally invasive spine procedures such as cervical disc replacement and microdiscectomies are performed at ASCs, but a significant portion of complex cases such as multilevel fusions and scoliosis are still being done in the hospital setting.
Four spine surgeons discussed the barriers stunting the transition of complex spine surgeries to the ASC setting and what changes could accelerate the migration of these cases.
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Editor's note: Responses were lightly edited for clarity and length.
Question: Why has the pace of spine surgery migration to ASCs not kept up with that of joint replacement in recent years?
Wesley Bronson, MD. Mount Sinai Health System (New York City): Ample research has demonstrated the safety of performing outpatient spine surgery in ASCs, especially for common procedures such as microdiscectomy, laminectomy, [anterior cervical discectomy and fusion] or cervical disc replacement, and even some more complex cervical and lumbar fusion procedures. Through a combination of careful patient selection, preoperative planning and perioperative techniques, complications are low and the need for transfer to a formal hospital are low. Nonetheless, many surgeons are reluctant to transition these patients into ASCs due to the potential for complications that may be difficult to manage in an ASC such as hematoma, airway compromise, [cerebrospinal fluid leak] leak or intractable pain. I believe as more research is published demonstrating the safety profile of these procedures in the ASC setting, more surgeons will feel comfortable transitioning more procedures out of the hospital setting.
Ehsan Jazini, MD. Virginia Spine Institute (Reston): Spine surgery is much more heterogeneous compared to joint surgery. The spine involves multiple joints and levels with a higher degree of complexity, especially for multilevel procedures of the cervical or lumbar spine. The smaller minimally invasive procedures such as endoscopic, microdiscectomy, and one or two levels cervical disc replacement fusion are being pulled to ASCs but the larger multilevel fusions and scoliosis surgeries are difficult to transition to ASCs due need for expensive technologies as well as the need of more intensive aftercare.
As spine surgery is becoming less invasive, using highly specialized training combined with enabling technologies, this will gradually change. At Virginia Spine Institute, we have also tailored and developed enhanced recovery protocols, known as the enhanced recovery after surgery program, that has led to faster recovery for patients, especially for more complex surgeries.
Philip Schneider, MD. The Centers for Advanced Orthopaedics (Bethesda, Md.): Spine surgery is migrating at a steady pace to the outpatient setting. There appears to be a differential because spine surgeries such as ACDF and lumbar discectomies moved to the ASC setting earlier. Total joint procedures hadn't migrated until more recently, with advancements in direct anterior and other techniques. In spine surgery, the big shift will occur when we start performing more lumbar fusions — which require more equipment — in ASCs. Once we get past that hurdle, we'll see a faster migration of spine surgery to ASCs.
Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: Spine surgery is a variable, highly individualized surgery. The results are, unfortunately, not as reproducible as joint replacement, even in the best hands. The acuity of the cases as well as patient factors have driven surgeries out of the ASC and back to the hospital in some cases. Lastly, a downtrend in reimbursement and the reward of the stick rather than the carrot when your organization has done a good job has discouraged them from taking these cases outpatient when medically feasible.