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Is it Time to Add Spine?
Minimally invasive techniques and a strong reimbursement outlook are fueling the specialty's growth to more facilities.
Choll Kim
Publish Date: April 3, 2008   |  Tags:   Neurosurgery-Spine

We're on the cusp of some truly great developments in minimally invasive spine surgery. Technological advances are combining with favorable reimbursement, creating a promising future for the specialty. Carefully assessing the required instrumentation, patient expectations and staff training will help you reap the benefits of offering profitable, cutting-edge care with better outcomes, faster recovery times and shorter stays.

Minimally invasive is a key driver
When spine procedures exceed the complexity of discectomy or decompression, both short- and long-term positive results typically decrease. Many patients are simply afraid of undergoing a large open spinal procedure despite the reality that the outcome can still be beneficial.

The complexity of open spine procedures — success rates fall somewhere between 70 percent and 80 percent — creates opportunities for facilities hosting minimally invasive cases. That opportunity lies in the significant differences between the approaches used for minimally invasive and open procedures.

Instead of making one big midline incision, stripping all of the muscle away from the spine and removing a significant amount of bone, as is often the case with open procedures, minimally invasive surgery of the spine uses very different surgical incisions.

From that aspect, there is noticeable room for improvement. I believe that this will drive demand for minimally invasive spinal procedures in a dramatic way. Most patients in my practice specifically seek me out because of my minimally invasive expertise. Many of these patients have already seen several other surgeons who have offered surgical treatment, but these patients won't undergo open spinal surgery. I anticipate this patient demand to increase in the next few years.

This is in contrast to what is happening with total hip and total knee replacement surgery. The results of these open procedures were in the 90th percentile for success before minimally invasive procedures became a viable option.

Open knee and hip procedures worked. Patients got better. So when minimally invasive knee and hip options hit the OR, dramatic improvements over the status quo were hard to justify for both patients and healthcare professionals.

That made sense. A minimally invasive total hip or total knee procedure is not very different from a corresponding open procedure. The incisions are just smaller; the approach does not change significantly.

Instrumental changes
New approaches demand new instrumentation. Your surgeons can't take "open" instrument sets and adapt the tools to minimally invasive surgery. Over the last five years, the instrumentation technology has increased dramatically to keep pace with demand for smaller, more exact tools.

The latest instrumentation lets surgeons insert screws and guide rods into the spine through small incisions, many of them less than 1cm in length. Small instruments such as curettes, rongeurs and various probes are designed to let a surgeon look through a very small surgical opening without his hands or instruments impeding his view.

Instrumentation advances are further supported by the development of minimally invasive systems with intrinsic light sources. Technology is moving toward lighting that's built into the retractor, illuminating the surgical field from within instead from overhead, as traditional light sources do. Surgeons don't have to battle shadows when working in a space that's internally lit.

Manufacturers are beginning to recognize and seize opportunities to develop instruments suited for minimally invasive spine. Until recently only a few companies possessed the necessary technology to develop such precise instrumentation. But as more companies develop minimally invasive systems with specialized retractors, illumination, tools to do decompression and advanced instrumentation, you'll have more options for purchasing needed equipment and greater negotiating power when shopping for the best possible deal.

Equipping Your Facility

While surgeon preference and case mix will drive many of your equipment purchasing decisions, here's a rundown of the basics needed for any spine program.

  • Surgical tables. You want a table that will allow for easy fluoroscopic C-arm access, and a radiolucent Wilson frame is useful. Alternatively, you can position patients on a Jackson table, which allows easy C-arm positioning for kyphoplasty and vertebroplasty cases, especially when you're using two C-arms to visualize both the anteroposterior and lateral planes.
  • Retractor arm. Look for a device that's easy to set up, has a stable attachment and is designed for easy repositioning of the retractor during the case.
  • Instrument sets. Sets that are designed in a bayoneted fashion so that they don't obstruct the surgeon's view when he's looking down the tubular retractor are helpful. Micropituitary rongeurs (both the straight and upward-angled pituitaries) are also very helpful and can be used with micro up-and down-going currettes when working within the confines of the tubular retractor.
  • Drill. Your surgeons need a long, tapered drill to work through the tubular retractor while visualizing the surgical field. In most cases, an electric drill works better than an air-driven drill because it runs more smoothly and barely moves when powered. A vendor will often supply drills for little or no cost as long as the same vendor supplies and charges for the bits used during each case.
  • Retractor systems. You want a system that's versatile and easy to use, and usually one with a diameter between 22mm and 26mm. During the procedure, surgeons insert an initial K-wire under fluoroscopic guidance to the area of interest and use tubular muscle retractors to approach the spine for the placement of the tubular retractor. Many different tubular retractors are on the market and many of these can easily expand to give surgeons room to operate.
  • Visualization equipment. You can get operative visualization with either a microscope or an endoscope. A microscope has the benefit of surgeon familiarity, ease of use, three-dimensional visualization and versatility. Ideally, get a system with a small, easy-to-manipulate operative head and platform.
  • Radiographic equipment. You'll need a fluoroscopic unit for visualization during most minimally invasive spine cases.

— Mick Perez-Cruet, MD, MS, and Ramiro Perez de la Torre, MD

Dr. Perez-Cruet ([email protected]) is director of the minimally invasive spine surgery and spine program for the Michigan Head and Spine Institute at the Providence Medical Center in Detroit. Dr. Perez de la Torre ([email protected]) is a spine research fellow at the same facility.

More potential patients
The minimally invasive spine revolution is going to be a patient-driven phenomenon. Prospective patients can obtain information through a simple Internet search if they're looking for alternatives to what they perceive as potentially dangerous procedures (open spine surgery, for example) because of what they've heard and read about anecdotally.

Patients will learn through their research that there are dramatic differences between the results of open and minimally invasive spine procedures. Patients who used to stay in hospitals for days with lots of bleeding and pain can now undergo a minimally invasive procedure and often go home in a matter of one to two days. The patient perception of what spine surgery is like today, and what it should be and will be in the future, will drive patients to find the physicians who know how to do the latest procedures well.

It's only a matter of time before a critical mass of people realize spine's potential and the popularity of the specialty's minimally invasive techniques begins to snowball. We're going to see a very sudden change in the types of procedures that will be performed over the next five years. Even today, we can perform complex surgery for scoliosis, infections, tumors and trauma using minimally invasive techniques.

It is my contention that minimally invasive surgery will benefit sicker patients the most. In many instances, patients can't undergo a corrective spinal procedure due to their poor health. In the past, these patients were left to suffer without definitive treatment. The application of minimally invasive strategies creates treatment options for these unfortunate patients. With the increasing age of our society, it is likely that this scenario will become more commonplace.

With the development of new technology, surgeons can perform procedures that will appeal to a wider patient base. In the end, minimally invasive surgery will lead to an increase in the total number of cases performed because more patients will be willing to undergo new procedures that involve less post-op pain and faster recoveries.

Reimbursement supports growth
In my practice, the types of patients we see are changing dramatically. We have noticed that our minimally invasive program tends to attract patients who are knowledgeable about available treatment options and are attracted to minimally invasive surgery to treat their back pain. More and more patients are coming to us from out of town specifically to undergo minimally invasive procedures and they tend to have insurance plans that provide out-of-network coverage.

We're also seeing a greater number of patients willing to pay cash. If a patient undergoes an inpatient procedure, the costs incurred will often reach at least $50,000. But for an outpatient procedure, it may be much less, perhaps closer to $15,000 or $20,000. This figure fits into a range where people may be willing to pay directly for specialized procedures not covered by insurance.

Fortunately we don't have to rely on cash to drive our business, because reimbursement for minimally invasive spine procedures remains strong. Most minimally invasive procedures are charged with the same billing codes as open procedures. This includes laminectomies, fusions and instrumentation. That's another advantage of pursuing this business: Reimbursements have remained stable while the procedures necessary to treat patients, along with post-operative costs, are becoming less expensive.

A plan for success
If you decide to pursue minimally invasive spine surgery as a potential new service for your facility, it's important to understand that the investment will demand a significant amount of planning in the following areas:

  • Capital equipment purchases. To perform minimally invasive surgery correctly, you must purchase all of the necessary capital equipment. You'll need the proper imaging equipment, whether it's a C-arm or, as an alternative, new image-guided technology that takes pictures of the surgical site and creates virtual images for the surgeon to follow during surgery.

You'll need to negotiate cost-effective contracts with instrumentation companies. This technology can be expensive, and not every hospital or surgery center will have the ability to afford such purchases. However, this may be an advantage for centers that can successfully implement a minimally invasive program, as competing centers may not be able to keep pace with those adding the specialty.

  • Surgeons. Obviously, you need to find surgeons who are good at performing minimally invasive procedures. But good surgical skills aren't enough. Your surgeons must also be willing to commit to staying on top of the new surgical techniques and advancements, and be willing to take required courses to stay up to date with the associated technology, which is evolving rapidly.
  • Staffing. Similar to the surgeons, your regular OR techs and nurses might not be able to make the leap to assisting with minimally invasive spine procedures. You'll want to treat the addition of spine procedures as an entirely new and separate service line that will require appropriate staffing. The facilities that will do best when adding minimally invasive spine are the ones with a staff dedicated to staying current on developing technology and techniques. Less-devoted facilities will struggle to keep up.

The tipping point
A wave of change is building. Like most minimally invasive procedures in other areas of surgery, such as knee arthroscopy, shoulder arthroscopy and laparoscopic cholecystectomy, minimally invasive spine surgery will reach a tipping point and a sudden increase in case volume. I predict this will occur in about three to four years. Understanding the critical factors that are shaping the market for minimally invasive spine surgery will ensure successful implementation of this technology and guarantee your facility remains on the cutting edge of advanced medical care.