Anterior cervical discectomy and fusion surgery have traditionally been performed in a hospital setting. While some cervical spine conditions involving severe spinal cord compression and complicated deformity will continue being performed in hospital settings, most relatively young and healthy patients with nerve root compression or soft cervical disk herniations are routinely being treated with anterior cervical discectomy and fusion in an outpatient surgery setting. The relatively avascular and intermuscular approach to the anterior cervical spine combined with the illumination and magnification provided by new-generation operating microscopes have made one and two level anterior cervical fusion and disk arthroplasty a safe and predictable surgery in the outpatient setting. Here's an update.

Lumbar reconstruction and stabilization
The array of lumbar reconstructive and stabilization procedures you can perform in the outpatient surgery setting is increasing rapidly. Traditionally, pedicle screw placement for spondylolisthesis or scoliosis has been accomplished via significant muscular stripping and blood loss. The intermuscular approach of Wiltse, which was initially described as a surgical approach to lateral disk herniation, has now become the workhorse surgical approach for placement of pedicle screws. The advantages of this approach include the minimal surgical trauma associated with surgical exposure and the ease this approach allows for pedicle screw placement and decortication of the intertransverse gutter. With newer, motion-preserving, flexible and articulated rods, this approach can be a very atraumatic method of dynamically stabilizing a lumbar segment. Adjunctive, intralaminar decompression can be easily accomplished using this approach as well.

The interspinous space also represents a heretofore un-utilized surgical interval that is increasing its use in the outpatient setting. The X-Stop interspinous spacer was the first FDA approved and commercially available device for indirect decompression and stabilization of spondylolisthesis. This procedure can be done under local sedation with adjunctive local anesthesia. Patients can be discharged the same day or overnight. The early outcomes of this procedure and device appear promising. Newer interspinous devices are being investigated and this approach will certainly be increasingly utilized for lumbar stenosis and lumbar degenerative disk disease.

Lumbar interbody fusion in the outpatient setting is also being performed at an increasing rate. Utilizing the same paraspinal intermuscular approach for pedicle screw placement, a transforaminal window can be utilized to prepare the disk space and place an interbody device. An interbody spacer can be utilized with off-label use of bone morphogenic protein to effect a rapid fusion and avoid the morbidity associated with iliac crest bone harvest. Technically, performing transforaminal lumbar interbody fusion (TLIF) through a Wiltse approach does require a learning curve and, as with the cervical fusions, extensive personal experience and evaluation of patient outcomes is recommended before performing these cases in an outpatient setting.

The extreme lateral extracavitary approach to multiple intervertebral disk spaces is the most radical surgery that is being performed in the outpatient surgical environment. This approach utilizes a retroperitoneal interval requiring minimal incision length and minimal muscle division, but provides an extensive exposure to lumbar disk spaces and permits the placement of large anterior interbody devices.

The lateral approach to the spine by its anatomic approach avoids division of the large stabilizing ligament, the anterior longitudinal ligament, and therefore can be performed as a stand-alone procedure, or performed in a staged fashion with supplemental posterior fixation. As with the TLIF approach, the interbody devices can be packed with bone morphogenic protein to hasten osseous fusion and avoid iliac crest harvest.

In the midst of an evolution
While significant deformities may still require a hospital setting, select deformities and spine conditions can safely be treated in an outpatient setting. As studies further bear out longer-term outcomes of our limited stabilization interventions, our surgical tactics will continue to progress. Improved technology and our deeper understanding of the spine will certainly provide further substrate for this evolution.