THIS WEEK'S ARTICLES
Outpatient Spine Is Hot
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."
The Future of Minimally Invasive Spine Surgery
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."
Addressing the Opioid Crisis with Minimally Invasive Treatment Options for Patients With VCFs
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: To learn more about vertebral augmentation, visit medtronic.com/VAEvidence.
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.
Behavioral Pain Management Education Benefits Spine Patients
New pathway improves outcomes, boosts patient satisfaction and lowers healthcare costs.
Many lumbar spine surgery patients experience persistent postoperative pain that can lead to emotional distress, impaired quality of life and increased healthcare costs. In an effort to mitigate these issues, Cleveland Clinic's Center for Spine Health is offering its patients a perioperative behavioral pain management class.
"We are making a cultural shift, prioritizing behavioral pain care and reducing the stigma of psychological interventions," says Sara Davin, PsyD, MPH, a psychologist in the Center for Spine Health. "Just like patients with diabetes go to a diabetes self-management class or patients with obesity go to nutrition classes, patients with pain can attend a class to learn how to manage it."
TREK for Surgical Success is a two-hour, clinician-led class based on Stanford University's Empowered Relief self-management intervention. The idea is to provide a low-burden intervention that teaches essential skills for managing pain with the understanding that pain is both sensory and emotional, says Dr. Davin. Cleveland Clinic psychologists, nurses and nurse practitioners are trained and certified in the intervention. The health system created a standardized clinical pathway for the intervention. "Few people are actually making it part of standard of care, and we're aware of no other academic medical center that's using it for spine surgery," says Dr. Davin.
The online group class is offered to spine patients before or after surgery to help them establish a plan for long-term pain relief. Participants learn about and practice skills for pain relief, including relaxation exercises, and complete a survey to identify unhelpful pain thoughts with the goal of reframing those thoughts. "We tell patients to practice the skills before and after surgery," says Dr. Davin. "Then if they need additional help such as a one-on-one coaching session, we can do that."
The Center for Spine Health has analyzed participation rates and patient satisfaction with the class to determine whether it is improving patient-reported outcomes, specifically pain interference and pain catastrophizing. The class had a 61.5% engagement rate among 78 patients who were enrolled between July 2021 and March 2022, with 46.7% of the participants answering 10/10 when asked, "How likely are you to use the skills and information you learned?"
Dr. Davin says facilities interested in making behavioral pain management their standard of care and creating an appropriate pathway require executive buy-in, clinical champions and certified clinical instructors, with all providers at the facility educated about the program so they can better present it to patients. "Messaging about the program needs to be constant and consistent across the enterprise," she says.
Take a deeper dive into Cleveland Clinic's program in the journal Frontiers in Pain Research.
Three Hospitals Receive Advanced Spine Centers of Excellence Distinction
They are among five facilities nationwide recognized by The Joint Commission.
The Joint Commission recently recognized and certified three Northwell Health hospitals as Advanced Spine Centers of Excellence. The orthopedic surgery and neurosurgery teams at Long Island Jewish (LIJ) Medical Center in New Hyde Park, LIJ Valley Stream and North Shore University Hospital (NSUH) in Manhasset run the only such programs in New York State to earn this designation, and are now among just five facilities nationwide recognized by The Joint Commission.
Northwell Health, New York State's largest health system, handles more than 4,500 surgical spine cases annually, ranging from minimally invasive procedures and same-day surgeries performed in outpatient centers to complex in-hospital surgeries addressing all manner of spinal conditions. The three recognized facilities perform more than 1,300 surgical spine cases combined each year.
Northwell's spine program is supported by advanced technologies such as guided navigation and robotics. "Our program offers comprehensive patient care from start to finish," says Jeff Silber, MD, associate chair and chief of orthopedic spine surgery at LIJ Medical Center. "All patients undergoing surgery attend Northwell's preoperative spine class, complete an in-hospital therapy program starting on the day of surgery and continue postoperative care at home or rehab with constant communication with the primary surgical team."
"It really does take a village to properly care for a patient with a spinal problem," said Daniel Sciubba, MD, MBA, senior vice president of neurosurgery at Northwell Health, chair of neurosurgery at NSUH and LIJ, and co-director of Northwell's Institute for Neurology and Neurosurgery. "Our teams in place have therefore taken extraordinary efforts to create patient centricity for spinal care. The patients' needs and expectations must constantly be at the center of what we provide. In the process, patients and their families do better, and the providers receive the ultimate satisfaction in seeing them improve."