ROOM FOR GROWTH Facilities filled with the latest technologies are perfectly positioned for same-day spine.

A challenging reimbursement landscape may have splashed some cold water on the heat outpatient spine was generating only a few years ago, but the specialty is still an up-and-comer with an enormous amount of untapped potential, thanks to improving minimally-invasive techniques and several technologies essential to achieving successful outcomes in the outpatient arena.

Which spine procedures are routinely done in outpatient surgery centers? Microdiscectomy, pain procedures involving spinal cord stimulators and percutaneous kyphoplasty have become the norm. I'm also performing single-level and 2-level lumbar interbody fusions, microdecompressions, laminoplasty, extreme lateral interbody fusions (XLIFs) and direct lateral interbody fusions (DLIFs).

Anterior cervical discectomy and fusion (ACDF) procedures were almost all performed in inpatient settings just 10 years ago, but more so for legal concerns: Some surgeons were overly paranoid of the marginally higher risk of patients developing breathing problems at home if a wound hematoma or swelling developed following surgery. Now, many surgeons are performing these procedures outpatient, and the hope is more will do the same.

One of my studies compared the outcomes of true minimally invasive surgery, which involves percutaneous procedures performed through tubular retractors with X-ray guidance, with conventional open surgeries and mini-open techniques, which involve smaller incisions and the occasional use of tubular retractors or image guidance.

My comparison of the techniques showed conventional open surgery had the most blood loss, which makes sense. The truly minimally invasive procedures had the lowest blood loss but the longest operative times, which also makes sense because they can be the most technically demanding to perform. They also had the highest complication rates, because it's easier to misplace a screw when you're working through a tiny hole and relying on image guidance, which is not infallible.

Mini-open, a hybrid between minimally invasive and conventional open techniques, had the best outcomes in my hands, but surgeons must focus on techniques with which they're most comfortable and best at performing, regardless of the label they fall under. I've found that the mini-open technique led to shorter hospital stays and the best outcomes, but a surgeon who's most comfortable with conventional open approaches might in fact have better results, even if the technique is associated with greater blood loss.

IN THE ZONE Surgeons must operate how they feel most comfortable, regardless of what label their preferred technique falls under.

Essential elements
Any procedure suitable for the outpatient setting should be done there. Here are a few key technologies that help improve same-day surgery outcomes:

• Microscopes should provide 3D viewing capabilities from the observing scope used by surgeons' assistants, who are active during spine cases and critical to surgical success. Providing surgeons and assistants with matching views of the action is key to maintaining flawless communication at the table and improved case efficiencies and outcomes. The microscope should be well balanced and ergonomically comfortable. If it's not, your surgeons deserve a new model.
• 3D image guidance can be like having a CT scanner in the OR. Not only can you navigate off the images for more technically accurate surgical approaches, but you can also use the images to verify proper hardware placement. It's ideal for surgeons who are moving toward performing transforaminal lumbar interbody fusions on an outpatient basis. Only a few surgeons are attempting these cases, but hopefully more will soon.

TABLE FOR TWO Spine scopes should be well-balanced and provide surgeons and their assistants with matching views of surgery.

I prefer to use a C-arm that lets me switch between 3D and 2D images mid-procedure so I can seamlessly navigate and assess my progress. Another popular 3D imaging option, the O-arm, requires surgeons to take the equivalent of CT scans every time they navigate along the spine, which subjects patients to increased radiation exposure. While somewhat large and cumbersome, the O-arm produces high-quality images, which is essential during certain high-risk cases.

• Tubular retractors used to access the spine are critical to the success of certain minimally invasive approaches, such as far lateral microdiscectomy involving a Wiltse dissection, during approaches to the lumbar spine. Many surgeons rely on tubular retractors for a large variety of surgical procedures.
• Headlights are especially important during microdiscectomy or ACDF for surgeons who prefer to forgo using a microscope. Surgeons want lightweight, comfortable models that let us adjust the intensity and diameter of the light field.
• Intraoperative neuromonitoring uses numerous electrophysiologic monitoring modalities for a variety of reasons, including to help identify malpositioned screws. Loss of transcranial motor-evoked potentials or somatosensory sensory-evoked potentials during procedures may alert you to possible complications that might have otherwise gone unnoticed.

Use of electrodiagnostic monitoring during spine surgery is controversial because its efficacy has yet to be proven by Class I clinical data. In my experience, however, it's a critical component of improved patient safety and case outcomes, especially involving instrumented minimally invasive cases, where visualization tends to be more limited.

• Power tools are largely based on surgeon preference. Plenty of good options are available: pneumatic, electric, battery-powered, hand- or foot-controlled with varying speed settings. I prefer foot-pedal controlled tools with graded speed options because they give me greater control of power and torque, and provide more stability around delicate spine anatomy.
• Tables must be radiolucent so segments don't block views or destroy the quality of 3D images used during navigation or verification of hardware placement. Look for user-friendly designs that make engaging and adjusting the table's surface simple and easy. Patient safety is a primary concern. Ensure the table has comfortable padding that protects pressure points during lengthy procedures and is designed so patients remain secured to its surface during mid-procedure positioning adjustments.

GRADUAL MIGRATION
Medicare Stymies Spine's Potential

SITE OF SERVICE Spine cases are performed where reimbursements flow easily.

Spine cases continue to shift to the outpatient setting for a variety of reasons, including undeniable cost savings, but private insurers are extraordinarily slow to adapt, mostly because they follow the lead of Medicare's antiquated reimbursement policies, which still require that all spine surgeries be performed as inpatient procedures.

According to Medicare, spine procedures can't even be performed in the outpatient department of an acute care hospital. Well, that's not technically correct. Hospitals can send patients home the day of surgery, but only after going through the song and dance of admitting them first.

That negates the cost-effectiveness of performing the procedure. It also increases the risks of post-op complications: The literature shows complications jump by as much as 800% the minute patients are admitted following surgery due to hospital-acquired wound infections and pneumonia. Hospitalized patients are also at increased risk of deep vein thrombosis and urinary tract infections because they rarely ambulate adequately after surgery.

Admitting patients unnecessarily after spine cases to meet Medicare's demands results in higher-costing procedures with worse clinical outcomes, which is exactly what Medicare punishes surgical facilities for. Elderly patients, who make up about 30% of my caseload and are often on Medicare, are at the highest risk of developing post-op DVT and pneumonia. Does it make sense that they're the ones we have to operate on as inpatients? It's a vicious cycle.

Because of Medicare, it's become increasingly difficult to negotiate with third-party payors that are used to paying for inpatient spine surgery, even though we're bringing them significant cost-savings and lower complications rates in outpatient settings.

In fact, a local hospital is the majority owner of one of my joint-venture surgery centers. Even though the hospital already has established contracts with carriers, we still can't get contracts to do cases. We've found that most payors negotiate ridiculously low rates that wouldn't sustain most surgery centers, so patients and doctors are left without the benefits of improved outcomes and substantially less use of healthcare's limited resources.

Spine's outpatient migration continues, but it's a very, very slow process that's failing to capitalize on the specialty's true potential.

— Alan Villavicencio, MD