August 18, 2022

Growth opportunities abound thanks to new techniques, better anesthesia and improved pain control.

Spine surgeries used to require a six-inch incision and a saber saw to cut through muscles. Patients lost a lot of blood and managing their post-op pain required several days of convalescence in a hospital.

Those days are gone. Surgical advances and new anesthesia treatments have made today's procedures shorter with less blood loss, a lower risk of complications and significantly milder pain levels.

"Minimally invasive spine is a movement over the past seven or eight years that is gaining momentum every year," says Alexander R. Vaccaro, MD, PhD, MBA, president of Rothman Orthopaedics in Philadelphia, which is planning a national expansion. "Patients, surgeons and payers prefer it. Everybody loves it, which is why spine surgery is the hottest topic in ambulatory surgical center circles today."

Today, minimally invasive surgeries allow patients who have undergone microdiscectomies, anterior cervical discectomy and fusions (ACDFs) and lumbar fusions to be safely discharged within 24 hours of their operations, says Dwight S. Tyndall, MD, FAAOS, a spine surgeon in the greater Chicago area. With appropriate anesthesia, effective pain control and a sound rehabilitation plan, Dr. Vaccaro estimates that two-thirds of all spine surgeries can be performed in an appropriately staffed ASC. Research shows that single- and two-level ACDFs are safe in an outpatient setting, as are some three-level ACDFs.

Improved patient selection criteria and pre-op optimization have also been factors in the expansion of same-day spine procedures. Rothman employees, for example, use artificial intelligence to analyze patients' height, weight, comorbidities, age, prior surgeries, smoking history and other characteristics to see if they are appropriate candidates for outpatient ACDFs.

Dr. Tyndall won't perform an outpatient ACDF on an otherwise healthy 45-year-old patient if their BMI is 40 or above. "It makes even minimally invasive approaches much harder simply because there's so much more tissue to work through," he says. "That means it's going to be a longer procedure and therefore there will be more risks for complications, so it's better to work with most of these patients in an inpatient environment." Lumbar solutions, however, can be safely performed in outpatient settings on patients with BMIs as high as 50, according to Dr. Tyndall.

Transitioning from traditional general anesthesia to IV anesthetics allows patients to wake up without feeling groggy, which hastens recoveries and makes for fast and safe discharges, says Dr. Tyndall. He points out that replacing most opioids with combinations that include IV acetaminophen, antibiotics, gabapentin, pregabalin and steroids has helped make outpatient spine procedures a reality as well.

"Hospitals should be tertiary and quaternary care centers where surgeons perform complex cases such as revision hip arthroplasty, scoliosis surgery, trauma cases, and tumor and infection procedures," explains Dr. Vaccaro. "The trend for elective cases to be in an outpatient setting needs to continue."

Dr. Tyndall agrees, saying he's grateful to provide patients with relief from chronic pain while gaining access with incisions one-third the size he used only 10 years ago. "I can't tell you the last time I used a saw saber or the last time I actually had to order labs after surgery to check a patient's blood count," he says. "It's just not necessary anymore because the procedures have become so miniaturized that the amount of blood loss is miniscule."

A new percutaneous technique leads to safer procedures and same-day discharges.

Uzma Samadani, MD, PhD, a neurosurgeon who operates at the Minneapolis VA Health Care System, in April became one of the only surgeons in the U.S. to perform a fully percutaneous oblique lateral lumbar interbody fusion (OLLIF) with navigation assistance.

The procedure, which is used to treat spinal stenosis, herniated discs and degenerative disc disease, is representative of how traditionally invasive spine procedures are evolving to become more minimally invasive, a development that benefits patient care and could help push more cases to outpatient facilities.

Dr. Samadani performs the procedure through a 15mm incision, which leads to less blood loss — total blood loss for the first four cases she performed averaged less than 25cc per patient — and requires no muscle detachment around the spine. No infections have occurred in 1,500 procedures performed so far across the country.

After undergoing the procedure, many patients can ambulate within hours and are ready for discharge soon after. Additionally, because of the low-risk nature of the procedure, it can be performed safely on elderly patients and those with high BMIs.

"Outpatient percutaneous spine surgery represents the future, and I am happy to be able to offer it to my patients," says Dr. Samadani. "The procedure reduces surgical time, muscle and soft tissue disruption, and blood loss to enable faster healing and mobilization."

Study: 57% of patients treated with vertebral augmentation able to reduce, stop pain drugs

Medtronic sponsored a study on the impact of minimally invasive vertebral augmentation treatments for painful vertebral compression fractures. The study found that procedures such as Balloon Kyphoplasty (BKP) and Vertebroplasty (VP) might provide an alternative to opioid pain medications for patients with VCFs. Among the study's findings:

• 48.7% of patients discontinued the use of oral opioids.
• An additional 8.4% lowered their dosage, compared to pre-surgery levels.
• A significant decrease in all-cause post-surgical costs.

The study, "Trends in opioid use following balloon kyphoplasty or vertebroplasty for the treatment of vertebral compression fractures (Ni, et al.)¹," was published in Osteoporosis International. A 7-month retrospective analysis compared opioid use and hospital visits in 8,845 patients before and after a BKP/VP procedure.

• 75.3% of patients underwent BKP and 24.7% underwent VP, with a mean age of 77.
• Among the 75% who filled an opioid prescription at baseline, 48.7% of patients discontinued opioid medication and 8.4% reduced their average daily dosage within 7 months' follow-up.
• Total payer costs significantly decreased over 7 months follow-up relative to baseline among patients who decreased or discontinued opioid use (-$6,759); while total costs increased (+$160) among those whose dosage remained the same, increased, or newly started.

More than 800,000 VCFs occur each year in the United States due to osteoporosis. These injuries can cause severe pain, limited mobility and reduced quality of life. VCFs traditionally were treated with nonsurgical management including bed rest, bracing and pain medications. Over the years, however, studies comparing balloon kyphoplasty to non-surgical management have shown balloon kyphoplasty produced better pain relief and quality of life for patients with acute VCF compared to patients treated with non-surgical management.^2-4

Medtronic's Kyphon™ balloon kyphoplasty is a minimally invasive surgical procedure for the treatment of spinal fractures due to osteoporosis, cancer or non-cancerous tumors. Although the complication rate for Kyphon™ balloon kyphoplasty is low, as with most surgical procedures, serious adverse events, some of which can be fatal, can occur, including heart attack, cardiac arrest (heart stops beating), stroke and embolism (blood, fat or cement that migrates to the lungs or heart). Patient results may vary. This procedure is not for everyone. A prescription is required.

Note: Complete safety information

Note: To learn more about vertebral augmentation, visit medtronic.com/VAEvidence.

References:

1. Ni W, Ricker C, Quinn M, Gasquet N, Janardhanan D, Gilligan CJ, Hirsch JA. Trends in opioid use following balloon kyphoplasty or vertebroplasty for the treatment of vertebral compression fractures. Osteoporos Int. 2021 Nov 2. doi: 10.1007/s00198-021- 06163-3. Epub ahead of print. PMID: 34729624.

2. Berenson J, Pflugmacher R, Jarzem P, et al. Balloon kyphoplasty versus non-surgical fracture management for treatment of painful vertebral body compression fractures in patients with cancer: a multicentre, randomised controlled trial. Lancet Oncol. 2011 Mar;12(3):225-35.

3. Boonen S, Van Meirhaeghe J, Bastian L, et al. Balloon kyphoplasty for the treatment of acute vertebral compression fractures: 2-year results from a randomized trial. J Bone Miner Res. 2011;26(7):1627-1637.

4. Van Meirhaeghe J, Bastian L, Boonen S, et al. A randomized trial of balloon kyphoplasty and nonsurgical management for treating acute vertebral compression fractures: vertebral body kyphosis correction and surgical parameters. Spine. 2013;38(12),971-983.