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The Essentials of Minimally Invasive Spinal Procedures
New surgical technology and advances in anesthesia let spine surgeons perform their less-complicated spinal cases in an outpatient setting.
Larry Teuber
Publish Date: October 10, 2007   |  Tags:   Neurosurgery-Spine

The traditional belief is that all neurosurgical procedures must be performed as inpatient cases. But with new surgical technology and advances in anesthesia, spine surgeons are able to perform cervical and lumbar disc surgeries in an outpatient environment. Here's how to do them efficiently, economically and safely.

Procedures to perform
The types of spinal surgery performed most frequently are in the cervical spine (neck) and lumbar spine (lower back) and less commonly in the thoracic spine (mid-back), sacrum and coccyx. The most commonly performed spinal surgeries are in the general areas of decompressions and fusions. Here's a breakdown of the procedures you can perform as outpatient cases.

  • Decompressions. Lumbar decompressions are all posterior approach procedures. These include lumbar discectomy, microdiscectomy (discectomy with use of microscope), endoscopic discectomy (with endoscope), laminectomy (removal of entire lamina), laminotomy (removal of partial lamina), foraminotomy and the Gill procedure.

We routinely perform up to two-level decompressions as outpatient procedures; decompressive surgery of three or more levels frequently requires an overnight stay. Posterior or anterior (from the front) lumbar arthrodesis (fusion) is rarely performed as an outpatient case.

  • Cervical procedures. Cervical procedures are performed from an anterior or posterior approach. Posterior surgery is very similar to posterior lumbar procedures. The most common cervical procedures are cervical decompressive discectomy, laminotomy and foraminotomy. These are best performed in the prone position with a horseshoe headrest or cranial fixation. Performing these procedures in the sitting position adds unnecessary risk and expense.

Posterior lumbar and cervical decompressive procedures are coded from 63001 through 63048. These cases may be performed as unilateral or bilateral and as single or multilevel.

  • Anterior cervical approaches. Anterior cervical disc procedures include four elements. The first is decompression of disc herniations or osteophytes (bone spurs). These are either unilateral or bilateral as a partial or complete corpectomy (removal of vertebral body). These procedures are coded from 63075 to 63088. The second element is the arthrodesis (fusion) across the decompression. These procedures are coded from 22548 through 22554 - and 22585 for additional levels. The third element is bone grafting. A bone graft might be an allograft (donor bone) or autograft (harvested from the patient). Typically these are structural grafts (solid pieces) and not morselized (many small pieces). The codes are 20930 through 20938. The final element is the installation of the anterior cervical instrumentation (plating). The code used for two segments to three segments is 22845.
  • Peripheral nerve procedures. We perform almost all peripheral nerve procedures in an outpatient setting. Here are a few tips that will enhance the financial efficiency of performing peripheral nerve surgery. Use local anesthesia; avoid blocks, tourniquets and general anesthesia. For peri-operative and post-operative pain control, administer Toradol (ketorolac tromethamine) IV pre-operatively. Avoid splints and casts; they increase operative time and material costs, and they serve no purpose on the most commonly performed surgeries such as carpal tunnel release, ulnar transposition and peroneal nerve release. Limit staff; nerve procedures require only a surgical scrub and circulator. Employ pre-op blocks; for an endoscopic release, place blocks in pre-operative holding.

Coming Soon: Outpatient Brain Surgery

Brain surgery will be performed on an outpatient basis by year's end, predicts David Baskin, MD, a neurosurgeon at Methodist Hospital's Neurological Institute in Houston. He says you can reach the anterior base of the skull by feeding a modified endoscope through a nostril and the sphenoid sinus cavity. Dr. Baskin says the procedure, which he's performed 400 times, is ideal for reaching tumors at the anterior base of the skull, with pituitary gland surgery being the most common.

"Going through the nostril is less invasive than traditional brain surgery, and I'm able to see and do things I couldn't do before," says Dr. Baskin. He credits the increased access and visibility to a longer, narrower endoscope specifically developed for the procedure. The endoscope provides a wider field of view than the narrow channel afforded by a microscope attached to a speculum. It can also be cleaned without pulling it out of the nose; a special irrigation system washes the lens clean without removing the scope, he says.

Reaching the front of the brain has involved going through the gums after making an incision under the upper lip; a technique that left patients heavily bruised, requiring an extended hospital stay and several weeks of healing. Dr. Baskin says recovery after the minimally invasive procedure has been remarkable, but patients are still admitted for 23 hours following surgery. In the near future, he believes patients could undergo the brain surgery in the morning, be observed until 7 p.m. or 8 p.m. and sent home.

- Daniel Cook

Essential elements
Developing the neurosurgery specialty in your facility requires more than knowing which procedures to perform. Here are other factors to consider.

  • Physician experience. The first consideration in adding outpatient neurosurgery to your facility is the confidence, training and experience of the operating surgeon. As a general rule, part-time surgeons don't perform spinal surgery as well as those who do spinal surgery as a major component of their practices. This is reflected in surgical complications, operative times, costs generated during surgery and time before a patient returns to work. Competent surgeons easily perform any of the surgeries I've mentioned as outpatient procedures.
  • Patient expectations. The second most important factor is promoting proper expectations among patients and their families. If any staff member - from the receptionist on down - tells a patient he'll be staying one night post-operatively, it will be difficult to convince the patient that going home the same day of surgery will be safe. We routinely inform patients that they will be discharged the day of surgery. If patients live beyond a comfortable driving distance from the facility, we pay for one night of local lodging. This expense is insignificant in relation to the cost of an overnight hospital stay.
  • Staffing concerns. Staffing for these procedures is standard: one circulator and one scrub tech. Most of our surgeons use their own physician assistants (PAs). From a cost-benefit standpoint and because of the restrictions placed on assistant reimbursement, we have little use for CNPs or certified surgical assistants. Surgeons who employee PAs on their own enjoy the increased revenue and efficiency PAs deliver. The facility also benefits because it is not required to staff the case with an assistant.
  • The OR. An operating room measuring 16 feet by 16 feet is of adequate size to perform most spinal procedures, except for those in the lumbar and thoracic spine that require multi-segmental instrumentation. (A standard operating room is at least 400 square feet or 20 feet by 20 feet).

Equipment needs
Efficient surgeons are able to perform complex surgery with basic equipment. Here are the supplies and instruments that we use, and those you should incorporate in a start-up practice.

  • OR table. We use a basic mechanical table. Previously, we used rolled and taped blankets to position patients prone for posterior spinal work. Now, we have a number of functional spinal frames constructed for under $750 apiece; there is no need to spend $15,000 for a specialized spinal frame or a spinal surgical table.
  • Hand instruments. Required hand instruments include dissectors, nerve root retractors, pituitary biopsy forceps, curettes, Kerrison punches, suction tips, needle drivers, pickups and scissors. Remember, expensive equipment will never replace an efficient surgeon.
  • Retractor systems. The retractors we use include Whetlaners, Gelpis and Williams, many of which we have modified for the obese patient. Anterior cervical surgery requires unique retractor systems. The least expensive is the Cloward and Caspar system. Because of the larger number of anterior cervical cases we perform, the Thompson retractor system is the most effective. Although it's more expensive, the Thompson retractor sets up quickly, requires infrequent intraop readjustments and, most importantly, replaces the need for a surgical assistant.
  • Cautery concerns. Cautery is provided with standard unipolar and bipolar techniques. There is little need for a Malis bipolar cautery irrigator. The initial expense of a Malis unit and the recurrent charge of the irrigating tubing make the use of the Malis financially inefficient.
  • Power drills. Many power drill units are available; the Midas and Stryker drills are the most commonly used. Expect to pay around $35 per drill bit. Some facilities re-sterilize these bits with no adverse effects.
  • OR Microscope. The secret to purchasing operating microscopes is to buy used and always buy the same type if multiple scopes are necessary. For spinal surgery, a basic microscope is all that is needed. We purchased a used Zeiss Superlux 300 in great condition for less than $50,000.
  • Cervical implants. Implants and bone grafts are a large part of the cost of performing cervical disc surgery. You can only achieve maximum cost efficiency and financial performance if every surgeon agrees to use the same cervical plating system. Your greatest purchasing leverage is obtained through quantity purchases and exclusivity. Don't expect to pay much more than $1,500 for a single level cervical plate; and with volume purchasing you can drive these costs down to about $800 for plates and screws. One more thing: Always secure the devices on a consignment basis with the instruments thrown in for free.

A Lucrative Specialty

Minimally invasive spine surgery can be a lucrative specialty. In a conservative estimate, most neurosurgeons can perform at least four cases a week in an outpatient setting. Calculating an average case reimbursement of $4,800 and an operating margin of about 50 percent, the marginal annual net revenue and earnings per surgeon should be $1,000,000 and $500,000, respectively.

Anesthesia protocol and pain control
Smooth anesthesia induction and quick emergence with minimal nausea are key to successful outpatient spinal surgery. We commonly perform surgery as an outpatient procedure on Class III anesthesia patients. Anesthesiologists who are dedicated to outpatient service and who have a unique awareness of customer service toward the patient and operating surgeon perform the best anesthesia. We routinely administer Decadron (dexamethasone) pre-operatively, which helps with pain control and nausea. We give Toradol (ketorolac) 30mg IV 30 minutes before the end of the case. Administer oral antibiotics (Keflex 500mg BID) for three days to five days post-op.

The most common reason neurosurgery patients are hospitalized is surgeon preference, but the next two most common reasons are pain control and patient nausea. We routinely place Jackson Pratt drains in the wound for all anterior cervical surgery and multilevel lumbar decompressions. The patient's family or visiting nurse removes these drains the next morning. Pain control begins with meticulous surgical technique, hemostasis and infiltration of the paraspinal muscles with Marcaine (bupivacaine) before closure and Toradol IV before the end of the case. Nausea is an anesthesia challenge but should be the least frequent reason for an inpatient stay.

Back to the future
The addition of spinal procedures performed by well-trained and competent neurosurgeons will enhance operating margins and the real earnings of an outpatient surgery facility. It should take no more than a few weeks to develop and implement a well-executed plan that concentrates on the specialty's essential elements. And once established, neurosurgery is a high-margin growth sector and a potential financial boon for an outpatient surgical facility.