COMMON CONCERNS While blood loss is the primary concern during spinal surgery, dural tears are a close second, especially in more complex cases.

While microdiscectomies and laminectomies are relatively straightforward, more complex procedures like lumbar spinal fusions at one or two levels are pushing the outpatient spine envelope. And as the field grows, so does the focus on minimizing common problems and complications associated with spine surgery. If you're considering adding outpatient spine surgery to your facility, or want to expand your current services, here are 5 things you need to know to make your cases safer.

1. Pick the right patient and the right surgeon
Preventing problems and complications starts well before the day of surgery. In fact, a strong patient selection process is one of the best ways to minimize the most common complications associated with spine surgery.

Patients must have few or no co-morbidities and be motivated before undergoing any type of outpatient spinal surgery. A 90-year-old who is on blood thinners is a poor choice, but a 38-year-old healthy woman who has attended all of her previous physical therapy sessions is likely to succeed. Additionally, while a surgeon may think the patient is an ideal candidate for outpatient spinal surgery, the decision should ultimately come down to whether the patient feels it is right.

You also need to ensure that you have the right surgeons performing these procedures at your facility. Before clearing surgeons for outpatient spine, make sure they can prove that they have a clear history with discharging their cases within 23 hours.

Be aware that not all spine cases are created equal. Just because a surgeon routinely discharges laminectomy patients the same day doesn't mean you should clear him for more complex procedures like lumbar spinal fusions. Also note that most surgeon fellowship training programs don't offer an "outpatient" program, so younger surgeons will likely have a steeper learning curve than veteran doctors.

Finally, the individual surgeon's technique also plays a role in avoiding complications. For example, in lumbar spinal fusions — the next big thing in outpatient spine — there are several techniques used with varying degrees of risk. Anterior lumbar interbody fusion carries the most risk for damage of the great vessels (aorta and vena cava), while a lateral lumbar interbody fusion has less of a chance of injury. Some minimally invasive posterior fusions carry lower risk in the outpatient setting, as they seem to also result in faster patient recovery.

2. Manage blood loss
As we mentioned, anterior lumbar fusions carry a high risk of uncontrolled bleeding and hemorrhaging, as the procedure puts the surgeon close to the great vessels. Even a small injury to these vessels results in multiple liters of blood loss within seconds. If you are performing these procedures, ensure that you have rapid access to a hospital in case of an emergency.

But blood loss isn't only a concern with anterior lumbar spinal fusions — bleeding is a common problem in most spinal procedures. While bleeding isn't a complication in and of itself, make sure it isn't excessive or impacting the surgeon's visualization during the procedure. Ensure that patients undergoing outpatient spinal surgery don't have a history of blood clotting or coagulation disorders. During the operation, check the patient's blood pressure frequently to ensure it's within a safe range.

You can do several things during the case to minimize blood loss. To help with initial bleeding, I often use a local anesthetic injection in the soft tissue, combined with epinephrine, which also helps to prolong analgesia. Additionally, during the procedure surgeons can use topical hemostatic agents — human thrombin-based formulas are most often used — for epidural bleeding. Newer agents feature specialized applicators to make their use easier in minimally invasive spine cases.

3. Have a plan for dural tears
While blood loss is the primary concern during spinal surgery, dural tears are a close second, especially in more complex cases. This injury occurs when the sac of tissue covering the spinal cord, called the dura mater, tears during surgery. It can cause patients' spinal fluid to leak, leaving them with severe spinal headaches and an increased risk of infection.

There's not a single best way to prevent these tears — most of it comes down to the operation itself and the surgeon's technique. Having good lighting and clear visualization, though, can minimize the risk. If a tear does occur during the operation, repairing it right then and there is crucial. The most common way to augment the repair of these leaks is to use a tissue sealant. New synthetic hydrogel sealants made for spinal surgeries are phasing out fibrin-based sealants since they provide watertight seals, don't need to be thawed and set in a few seconds.

However, for sealants to work properly, the patient must be kept in a certain position for an extended amount of time post-operatively — typically flat on their back, overnight. Because of this, your facility should have access to a hospital and have a solid transfer plan in place for patients with dural tears. Stand-alone ambulatory surgery centers with 23-hour programs also work well for these cases.

Sometimes, the tear isn't caught and repaired during the surgery. Be sure patients are aware of the risks of a dural tear before surgery and remind them at discharge to call their surgeon if they develop nausea, sensitivity to light and/or a severe positional headache while recovering at home.

4. Take precautions against SSIs
While studies have found that outpatient spinal procedures actually have a lower risk of infection compared to inpatient ones, you still must take precautions to avoid SSIs in your patients.

Typically with our spinal patients, we have them do a 4% chlorhexidine gluconate (CHG) scrub the night before and on the day of surgery. Your patients should receive clear pre-op instructions on how to use the scrub, and you may even consider providing the solution to them to ensure the protocol is followed. Then, on the day of surgery, patients are given prophylactic antibiotics. This is typically sufficient for our outpatient cases, and they don't require follow-up antibiotics.

Technique also plays a role in your infection control efforts. Open procedures have been clinically shown to have higher rates of SSIs compared to newer minimally invasive techniques, and studies show that the longer the procedure, the higher the chance of infection. Patients who smoke, or who use steroids, or who have diabetes, high BMI or are malnourished, are also at increased risk of infection; carefully monitor these patients.

Additionally, while inpatients have around-the-clock nursing in the days after spinal surgery, you must have other monitoring methods in place for your outpatients. Consider teaming up with a local nursing group to start a home recovery program, where a nurse can visit the patient a day or two after surgery and check for infections. This is especially important for your patients undergoing more-complex cases, like lumbar spinal fusions.

SAFER SPINE SSIs, dural tears and bleeding are some of the common complications of complex spine cases.

5. Use a multimodal
post-op pain management plan
Following most spinal surgeries, patients will experience some level of discomfort. While traditionally this was treated with opioids, new multimodal plans help to avoid the negative side affects associated with opioids and manage patients' pain more efficiently.

Compared to other surgeries, patients undergoing spinal procedures are more likely to already be using long-term opioids to treat chronic pain. A multi-pronged approach using some combination of local anesthetic, NSAIDs, gabapentinoids and/or acetaminophen can help control pain, especially for patients with a high opioid tolerance. Additionally, some surgeons have success using pain pumps or a liposome injection of bupivacaine in more complex outpatient spine cases. Surgeons should work with anesthesia providers to develop a consistent pain management protocol.

But sometimes with spinal surgery, patients feel more than just the typical discomfort. Post-op radiculopathy — where the patient has radiating pain that stays the same as it was before surgery or even increases dramatically — is a rare complication that does occur. Inflammation often causes post-op radiculopathy, but it can also be the result of misplaced instrumentation. Surgeons can decrease their odds of making these errors by using low-dose C-arms for intraoperative imaging, or newer spinal navigation systems to ensure their accuracy during the procedure. Notify patients of the risk of post-op radiculopathy, and tell them in their discharge instructions to call their surgeon immediately if they're experiencing the same or increasing levels of pain or weakness in their back or legs after surgery.