VIEW MASTERDr. Khurana employs minimally invasive, muscle-sparing techniques and microscopic advances to make outpatient spine fusion a reality.

Spinal fusion surgery bonds and immobilizes cervical or lumbar vertebrae to alleviate disc degeneration, instability, stenosis, scoliosis and other spinal disorders. While it has traditionally been an inpatient undertaking, recent developments are making outpatient fusion not only possible, but preferable. Here are 4 key factors driving that transition.

1. XLIF
For lumbar fusion, the development of a minimally invasive technique through an alternative approach has enabled less traumatic access to the anterior spine. Extreme lateral interbody fusion, also known as XLIF, is exploding in popularity among spine specialists. With the patient positioned on his side, we enter through a small incision in the flank, between the lower rib margin and the iliac crest. By avoiding an abdominal incision and by dilating, not dissecting, the muscles of the back, we're able to reach the disc space, remove the damaged disc, and insert the bone graft material and fixation device with minimal trauma.

We're guided throughout the procedure by fluoroscopic imaging to visualize the spinal structure and neural monitoring to determine how close our instruments are to spinal nerves. But advances in operating microscopes' illumination and magnification really give us an aggressive view, on a plane-by-plane and tissue-by-tissue level, of our impact on the anatomy and the results we're likely to deliver. XLIF has a steep learning curve, but surgeons who are motivated to learn the technique will see a dual payoff of solid outcomes and patient satisfaction.

2. Can-do patients
Patient selection is key to safe, predictable and successful outpatient spinal fusion. There is a significant subset of the population — the young, healthy, motivated patients with limited co-morbidities who are amenable to education on outcomes and recovery, and who want to avoid the inpatient stays and associated risks of hospitals — who do extremely well.

Outpatient isn't ideal for every patient, of course. Studies suggest that those requiring fusion on more than 2 levels are better treated in hospitals, as are those with severe spinal cord compression, complicated deformities, or multiple co-morbidities such as obesity and heart disease, in order to ensure observation and access to immediate multi-specialty critical care if it becomes necessary.

One hurdle to building an outpatient spinal fusion service line is economic. Medicare doesn't list an outpatient code for the procedure, and many commercial insurers don't cover it. But as we continue to produce high-quality outcomes and satisfied patients, and as carriers take note that outpatient fusion can be done at a fraction of the cost of hospital surgery (possibly representing millions of dollars in healthcare cost savings), that will be a large incentive for federal and private insurers to change their tune. Economics will carry the day.

3. Outstanding outcomes
We've been doing same-day spinal fusion since 2006, with excellent outcomes. We're done within one-half or even one-fourth of the time it would take us in a large hospital setting. And since our patients are able to mobilize reasonably quickly after the procedure — they're sitting in a chair, walking, urinating and tolerating nutrition within a couple of hours, supported by nothing more than oral pain medications — we can discharge them after an 8-hour, or at the most a 23-hour, recovery to convalesce at home. We've seen few complications, and our patients return to normal activity in a comparatively short 4 to 6 weeks. The true sign of success? Patients satisfied with their outcomes have been telling others about us and our work, and encouraging them to go outpatient, too.

4. More opportunities to learn
Outpatient spinal fusion cannot be mastered without the mentoring of an experienced practitioner. As the benefits of the procedure increase its prevalence, there are more and more of these mentors from whom to learn. In my own experience, meeting Dr. Robert Bray, the CEO and founding director of the DISC Sports & Spine Center, was enormously valuable. He'd expressed his sense that many, many surgeries could be performed on an outpatient basis, including the spinal fusions I was doing in high volume. When I observed his techniques and his patients' outcomes, I knew his assessment was technically achievable.

Unless you see outpatient spinal fusion with your own eyes, it may be hard to believe. But it is possible, and everyone benefits.