Welcome to the Spine Surgery Revolution;
Related Story: My Personal Experience with Spinal Surgery – Click to Read

Minimally invasive techniques and surgeons who continue to push
the envelope have helped create a new industry.
Robert S. Bray Jr. M.D.
Outpatient Surgery Magazine – November, 2007  

 

In Good Hands:  The outpatient spine surgeon should be fellowship trained in minimally invasive techniques and cautious in selecting patients.
Hardware Upgrades:  Advances in spinal implants have fueled the transition of spine cases form the inpatient to the outpatient setting.

 

This is a thrilling time in spine surgery's development. The specialty is evolving and we're just now seeing the results of a minimally invasive revolution, Most spine surgeons currently perform only 5 to 10 percent of their cases on an outpatient basis, But these numbers are expected to grow over the next five to seven years as minimally invasive spine techniques become integrated, outpatient spine centers are built and cases continue their exodus from the inpatient environment to the outpatient setting. Pay attention. Stay educated. Get excited. We're in the midst of a rapid reorganization of spine services and the creation of an entire new industry.

New Expectations

Spine surgery's inpatient-to-outpatient evolution represents a paradigm shift that differs from other fields. Specialties that previously transitioned to ambulatory centers have focused on low-acuity, high-volume surgical procedures with rapid turnover and minimal post-operative care required. Spine surgeons push the outpatient envelope by operating on higher acuity patients that demand an increased complexity of intraoperative and post-op care. Transitioning spine cases to the outpatient environment is clearly more complex than converting lower-acuity cases.

So why has spine migrated to the outpatient environment? Having started performing outpatient spine cases about seven years ago with select lumbar microdiscectomy procedures, and having progressed to performing a full spectrum of spine surgery cases, I've seen firsthand the factors that have made this transition possible.

Improved patient care.  This is first and probably most important.  Over a four-year period as the director of the spine program at Cedars-Sinai Medical Center in Los Angeles, I oversaw an improvement in post-operative protocol management that decreased the stay of spine patients from an average of 5.7 days to 1.7 days.

Adequate patient education, setting patient expectations for a streamlined recovery and seeking the involvement of patients' families in our recovery efforts have helped reduce this time to a current average of only eight post-op hours.

Rapid mobilization. Rapid post-op mobilization of the spine patient is well tolerated and reduces post-op complications. But rapid mobilization of the patient is often difficult and takes some getting used to for those trained in an inpatient setting. The recovery nurse has to be trained in physical therapy and pain management, and must serve as nurse educator to her staff, the patient and the patient's family. Obviously, spine surgery can't be done on an outpatient basis without highly trained and motivated nurses.

Managing patient perceptions. Molding our patients' pre-op perceptions has been an interesting educational task, as many who present for surgery assume that hospitalization is a requisite of spine surgery. Interestingly, many patients believe that they won't receive an adequate level of care if they're operated on in an outpatient environment. This misconception derives from outpatient facilities being perceived as low-acuity centers. The move to full-spectrum spine therefore requires an extensive development of post-op protocol management, cooperative commitment between the nursing staff, surgeons and anesthesiologists, good patient education and proper patient selection. Patients must be healthy and willing to buy into the fact that their post-op recovery can be accomplished safely and adequately without an overnight stay.

Proactive pain management. This is paramount to reinforcing the possibility of a same-day
recovery. You must maintain tight control of the patient's post-op pain without succumbing to the tendency to oversedate. The best way to control a patient's pain and speed recovery is to avoid rescuing patients who are in extreme discomfort.

Improved Technology

The surgical approach for spine cases has also undergone an evolution sparked by improved access to the surgical site. This improved access is without question a direct result of the developing operative microscope. Increased visualization and improved lighting provide a quantum leap forward from older surgical techniques.

Improved instrumentation has also played a major role in the outpatient spine revolution. Microcurettes, high-speed drills with micro handles and bits, and micro rongeur shavers work efficiently in the small access spaces required for this specialty. Older generations of instruments were comparatively clumsy and difficult to handle.

Outpatient spine doesn't have to represent a step down from the hospital inpatient environment. At our facility, we have 560-square-foot operating rooms, the most modem and complete equipment available, full HEPA filtration, ultra-clean rooms and a more experienced nursing staff for both pre- and intraoperative care than is available at some inpatient hospital programs.

Surgical training and experience cannot be understated. Your surgeons and operating team must complete the appropriate training and endure the inevitable learning curves before they can perform outpatient spine efficiently and safely. The outpatient spinal surgeon should be fellowship-trained in minimally invasive techniques and be realistic and cautious in patient selection. The spine surgeon should be able to perform the procedures at the highest standards in order to maintain a positive reputation in this developing surgical field.

Circulating nurses and scrub technicians, instrument technicians and radiology technicians all play a vital role in the successful case. Their knowledge of the procedures makes communication in the OR flawless and sometimes even wordless. When operating, I rarely if ever look up from my microscope.  The scrub tech has a high-resolution screen on a boom arm in front of his workspace to follow the progression of the case. The instrument I need at any given time is usually within easy reach of my hand without me having to ask for it. The circulating nurses recognize the flow of the case and make sure needed supplies are always on hand and readily available.

The spinal implant companies have pioneered most advances in stabilization and new procedures. For example, we're now using our fifth-generation cervical stabilization for arthrodesis. It offers efficient, safe performance of an anterior cervical discectomy and stabilization, letting the procedure be performed as an outpatient case. Implant manufacturers have also introduced new lateral approaches, lumbar stabilization with percutaneous systems and minimally invasive transforaminal lumbar interbody fusion.

Extensive thought and development has gone into the operative instruments as well as implant
systems to let spine procedures be performed on the majority of patients in a repeatable and efficient fashion. These advancements in implant technology let cases that were previously considered solely inpatient now be performed in the outpatient environment.

New implants are moving away from arthrodesis and toward motion technology. Disk replacements, dynamic stabilization, and ligament and cartilage regeneration are all on the near horizon. FDA studies will be completed shortly on new dynamic motion preservation devices. These devices will someday be used routinely. Many, if not all, of these systems will reduce patient morbidity, decrease OR time and increase the ability to mobilize a patient immediately after surgery.

These systems have been designed from the ground up with an eye on minimally invasive spine surgery techniques. Their introduction will further promote the advancement of spine into an outpatient environnment. For now, we routinely perform the following procedures on an outpatient basis:

• cervical anterior 1 or 2 level
• discectomy and fusions
• posterior approaches such as foraminotonlies, laminotomies and laminoplasties, including
multiple levels
• stabilization procedures (both arthodesis and motion preservation procedures)
• cervical artificial disks
• lumbar decompressions
• microdiscectomy
• stabilization with pedicle screw systems
• dynamic stabilization
• thoracic disk decompression.

Our facility doesn't currently host scoliosis-correcting surgery, but this may become an outpatient case in the future with the development of advanced percutaneous systems. We don't perform many anterior lumbar procedures because of the limitations of blood transfusion and the potential approach-related complications that currently keep these cases performed primarily in an inpatient setting.

Cautious Expansion

When a spine center is set up with the proper personnel and level of care, three things are bound to drop: your rates of complication, infection and maloccurrence. But there will always be political challenges in moving procedures that are traditionally inpatient into the outpatient setting. The future of outpatient spine depends on facilities that currently perform successful procedures to document and publish their positive results. Spine's pioneering centers need to continue their cautious expansion and training of both staff and surgeons to maintain the positive trend of this still developing specialty.