Leading spine surgeons who are using robotics, surgical navigation and ultrasonic bone-cutting technology to realign the spine, fix pinched nerves, place implants and fuse vertebrae are helping shift complex procedures to outpatient facilities.

"That's benefitting patients in terms of less pain and faster recoveries, but it's also resulting in measurable benefits such as lower rates of complications and blood transfusions," says Christopher Good, MD, FACS, a spine surgeon and president of the Virginia Spine Institute in Reston, Va.

It can also benefit your facility. Innovations in spine surgery and emerging technologies are giving surgeons the tools and confidence they need to perform a host of procedures in outpatient ORs, from posterior cervical foraminotomy (for relief of pinched nerves) and anterior cervical discectomy and fusion (ACDF) to minimally invasive lumbar laminectomy and discectomy. Medicare is also reimbursing for select spine procedures performed in surgery centers, including neck and lumbar fusions and cervical discectomy. Dr. Good believes the number of procedures Medicare will pay for in the outpatient setting — and the number of cases you can host — will only increase as technology continues to advance.

James Petros, MD, MBA, founder and medical director for Allied Pain & Spine Institute, saw spine as a growing specialty and helped design and open the Trinity Surgery Center in San Jose, Calif. The 3,000-square-foot center has hosted about 1,400 spine and pain-management procedures annually since opening its doors in December 2016.

Equipment costs accounted for 35% to 40% of the facility's 7-figure start-up budget, according to Dr. Petros, the facility's managing partner. On the purchase list: Jackson and Wilson table frames, (because surgeons have different positioning preferences), a C-arm (costing about $85,000), a surgical microscope (which can range in cost from $100,000 for a basic model to $500,000 for a high-powered, high-optic model). Dr. Petros and his colleagues also purchased pneumatic drills and spine instrumentation sets, including lumbar and cervical trays, retractors and implants.

Is investing in robotic technology worth it? Dr. Good thinks so. He says the price of a robotic platform ranges from a couple hundred thousand dollars to $1 million, depending on features needed to match the complexity of the procedures surgeon-users perform. That's a significant investment, for sure, but the improved accuracy afforded by the technology can help prevent costly post-op complications, points out Dr. Good. He says minor complications following lumbar spine surgery might cost $8,000 to treat, and a major one $30,000. Revision surgery, adds Dr. Good, could cost between $10,000 and $30,000.

Surgeons who use the technology map out the procedure and program it into the navigation system before they enter the OR. During surgery, a robotic arm guides the surgeon along different trajectories to intended sites along the spine, where he works instruments through the arm.

Dr. Good says robotic platforms with integrated surgical navigation compare how the actual surgery is progressing to the optimal pre-op plan mapped out based on the patient's specific anatomy. Surgical navigation technology also superimposes an image of the implant in the exact spot the surgeon had marked when setting the pre-op plan. Those real-time images eliminate the need to gradually maneuver an implant into place while snapping several C-arm images to confirm the hardware is placed accurately. Dr. Good says that benefit of surgical navigation can reduce radiation exposure to patients and surgical staff by more than 75%, another benefit to consider in a cost-benefit analysis.

He's bullish on what the future holds for same-day spine and robotics, which he's used to perform a wide range of procedures, from scoliosis reconstruction to lumbar fusions. Dr. Good is also one of the few surgeons in the world to have performed robotic endoscopic spine surgery.

"We're trying to move an entire group of patients over to the outpatient arena," he says.

Up for the challenge?

Outpatient spine has a lot of growth potential, but it's not for everyone. In order to safely and effectively tackle the specialty, you need to run a high-volume facility that hosts spine cases 5 days a week with highly skilled spine surgeons who perform at least 25 to 100 procedures per year, says Matt McGirt, MD, FAANS, a spine surgeon at Carolina Neurosurgery & Spine Associates in Charlotte, N.C.

Dr. McGirt says you also need to establish perioperative protocols to catch potential problems before patients are discharged. One such protocol at Dr. McGirt's facility involves making all ACDF patients stay in the PACU for at least 4 hours before discharge. That directive is based on research that says hematomas or neck bleeds nearly always occur in the first 4 hours of recovery. Of the 2,000 ACDFs Carolina Neuro-surgery & Spine has done, fewer than 5 patients had to be hospitalized post-op, but those patients were caught as a direct result of the 4-hour stay protocol.

As long as patient safety is made as much of a priority as surgical innovation, outpatient spine will continue to be an attractive option for progressive facilities. "It's no longer a question of if spine surgery can be done in an outpatient setting," says Dr. McGirt. "The real questions now are by who and when." OSM