November 24, 2021

The menu of procedures that can be safely performed in outpatient facilities continues to grow.

CREDIT: Joseph Blythe
REDUCING TRAUMA Oblique lumbar interbody fusion (OLIF), which requires a smaller incision and less dissection than the anterior approach, is becoming popular in outpatient settings.

As exciting developments continue to make complex spine surgeries simpler to perform, more of these procedures are moving from inpatient hospitals to outpatient operating rooms and even doctors’ offices. As a result, same-day spine has become one of surgery’s hottest specialties. Here is a look at some of the top spine procedures moving to outpatient facilities:

Balloon kyphoplasty and vertebroplasty. These are the two most common treatments of vertebral compression fractures. Vertebroplasty involves injecting cement to stabilize vertebrae fractures. The treatment works in a high percentage of patients with non-displaced, compressive eggshell-like fractures, according to Robert E. Jacobson, MD, a neurosurgeon and spine specialist with OMNI Spine Center in Miami.

Balloon kyphoplasty can help to restore vertebrae height in addition to repairing the fracture. A balloon is slid into the fractured vertebrae and expanded to correct the deformity before the cement is injected into the space. To help prevent subsequent fractures of adjacent vertebrae, some surgeons use a titanium implant that resembles a car jack inside the fractured vertebra before cement or acrylic is injected, says Dr. Jacobson. Once the implant is deployed and locked in place, the surgeon injects cement into the vertebrae body.

Lumbar fusions. With anterior lumbar interbody fusion (ALIF) and oblique lumbar interbody fusion (OLIF), spine surgeons make incisions through the back, front or the side. While ALIF can require a large incision, particularly in heavier patients, the OLIF incision is smaller at about two or three inches, which allows for minimal dissection of muscle and tissue and limited disruption to underlying retroperitoneal organs, says Joseph Blythe, MD, a fellowship-trained spine surgeon in Nashville, Tenn.

Artificial disc technology. New discs increase cervical spine mobility and put less stress on adjacent discs, which leads to quick recoveries for patients. First-generation discs resembled a marble, but subsequent versions have progressed to a sliding ball bearing. Recent artificial discs designed from nanofibers woven in a ring around a soft-cushion center better mimic a native disc’s structure and can produce superior outcomes in the cervical and lumbar spine as a result. "It’s difficult to find reasons not to do it," says Dr. Blythe. "Patients present with herniated discs or stenosis at one or two levels, and two weeks later they’re back at work with no pain or symptoms."

Options for future growth. Evidence is growing that one- and two-level anterior cervical discectomy and fusion (ACDF), anterior cervical discectomy and fusion can be performed effectively and safely in same-day surgical settings. Minimally invasive transforaminal lumbar interbody fusion (TLIF) is beginning to emerge as an outpatient option as well.

The continuing developments that continue to improve balloon kyphoplasty, as well as other procedures, make the future of cost-effective outpatient spine very bright.

Ten keys to improving their pre- and post-op care.

OPEN DISCUSSION Providers should communicate all aspects of the care pathway with spine patients before, during and after their surgical procedures.

Patients scheduled for spine surgery must do more than show up on the day of their procedure, cross their fingers and hope for the best. They should also prepare physically and emotionally, as well as arrange their homes for ease of movement upon their return, according to Hooman Melamed, MD, a physician based in Marina del Rey, Calif.

Here are 10 simple things Dr. Melamed recommends telling patients to make sure all facets of their pathway of care go as smoothly as possible:

Place things within easy reach. With limited mobility post-surgery, patients should place frequently used items such as cooking utensils and remote controls at torso height. This will limit how often they’ll have to bend forward or stretch high.

Purchase a toiler riser. The riser sits above the toilet seat so the patient doesn’t need to use their hips, knees and back during a deep bend to go to the bathroom.

Stop smoking. Nicotine increases the risk of complications after surgery by interfering with bone healing, and can also increase the risk of infections. Patients should take steps to quit smoking cigarettes and other nicotine products in the months leading up to surgery.

Buy slip-on shoes. Bending over to tie or buckle shoes is virtually impossible after spine surgery. Comfortable, supportive slip-on shoes are easier for patients to manage, and can make them feel self-sufficient by not having to ask someone else to help them get dressed.

Know your surgery. Encourage patients to ask questions and read about their upcoming procedures. Knowing what to expect will reduce their anxiety and frustration.

Prepare meals. Patients should have several easy-to-heat-up meals ready for the immediate days after they return from the surgery. Stocking the freezer with prepped meals is encouraged as well, as enough mobility for extensive cooking might not return for weeks.

Get a grabber. These lightweight poles with a handle that controls a pincher on the end will help patients pick up dropped socks or pens, so they won’t be tempted to bend down to retrieve them. They can also be used to get items they forgot to store at torso level.

Meditate. The practice can help patients break negative thinking patterns, reduce stress, allow them to stay in the present moment and combat thoughts that they should be feeling better than they do in the days after their procedures.

Donate blood. This precaution isn’t required, but can be prudent, especially if the patient has a rare blood type or if there are known blood shortages at the time.

Review medications and supplements. Some therapies can affect bleeding or interfere with the effects of anesthesia. Work with patients to wean them off problematic meds before their procedures.

Taking these steps will go a long way toward your patients experiencing quick, efficient and comfortable recoveries, says Dr. Melamed.

Identifying the right patients helps build successful VCF care pathway.

CREDIT: University Hospitals, Cleveland, Ohio
Richard Rhiew, MD.

Early diagnosis and prompt treatment can improve outcomes for patients with painful vertebral compression fractures, says Dr. Richard Rhiew, a board-certified neurosurgeon with the University Hospitals system in Cleveland, Ohio. Rhiew says relationships he has built over 10 years in the system have helped with identifying patients who could benefit from treatment via vertebral augmentation.

"A lot of it is just time — building those relationships with the primaries and the ER staff," Rhiew says. "There's a lot of patients that come through the ER and then eventually come to the office. There are referrals from primaries – the primaries see how well the patients do – and then there are inpatient consults where they just have so much pain they come to the ER, and they have to be hospitalized."

After getting referrals, Rhiew follows a plan to determine whether a patient should be treated with Balloon Kyphoplasty, a minimally invasive surgical procedure to relieve pain and stabilize the fractured spine.

"Usually, they already come with either an X-ray or possibly a CAT scan, and then we finish the work-up," Rhiew says. "I tell them the X-ray and CAT scan can't tell if these fractures are a day old or a hundred years old. It's only the MRI that can really tell that. The MRI is our gold standard, and we get that done to figure out which ones are acute and causing pain and fix those if they are failing conservative treatment."

Balloon Kyphoplasty

Rhiew pointed to one recent case to illustrate his workflow. The patient was referred thanks to a close relationship: Her daughter is a nurse in the operating room. "She has seen a lot of other patients who have this similar condition and how well they do after the procedures."

The patient, age 89 with osteoporosis, had a T6 fracture with a 50% loss of vertebral height. She had been sitting on a stool that collapsed, causing her to fall. Her pain had persisted and gotten worse for more than a month.

"She came in with a 10-out-of-10 pain on the pain scale," Rhiew said. "Between the time that she initially presented to the office with one possible fracture, by the time she was actually in surgery, she had many other fractures. We ended up treating five different fractures."

Although the complication rate for Balloon Kyphoplasty is low, as with most surgical procedures serious adverse events, some of which can be fatal, can occur including heart attack, cardiac arrest (heart stops beating), stroke and embolism (blood, fat or cement that migrates to the lungs or heart). Other risks include infection; leakage of bone cement into the muscle and tissue surrounding the spinal cord and nerve injury that can, in rare instances, cause paralysis; leakage of bone cement into the blood vessels resulting in damage to the blood vessels, lungs and/or heart.

Rhiew said he considers a patient’s quality of life and ability to do daily activities when deciding whether to treat.

"Some of these people, it takes them two hours just to get out of bed. If you can barely get out of bed, you live alone, you're 80, 85, 90, before you were totally independent, that really affects your quality of life," Rhiew said. "We tell them if you can tolerate the pain, it will heal naturally, but it'll take at least 6 weeks. If you're not 18 anymore, it could take 2 months, 3 months, who knows? If the pain is just not getting better, if medicine is not helping you, if a back brace does not help you, then the kyphoplasty can turn three months of pain into less than an hour of an outpatient procedure."

Note: The preceding testimonial contains the opinions of and personal surgical techniques practiced by Dr. Richard Rhiew. The opinions and techniques presented herein are for information purposes only, and the decision of which technique to use in a particular surgical application should be made by the surgeon based on the individual facts and circumstances of the patient and previous surgical experience.

Note: For more information, please go to https://www.medtronic.com/us-en/healthcare-professionals/therapies-procedures/spinal-orthopaedic/vertebral-augmentation/procedural-solutions/balloon-kyphoplasty.html?cmpid=Article_TradePublication_OutpatientSurgeryArticle2_DrRichardRhiew_UC202207582EN_BKP_FY22.

Minimally invasive procedures can produce significant pain relief.

A recent study says that balloon kyphoplasty and percutaneous vertebroplasty have been shown to increase the quality of life for patients with a form of bone marrow cancer who are living longer thanks to improved treatment options.

A narrative review that appeared in August in European Spine Journal analyzed 23 clinical studies that were performed as recently as February 2021. The study explained that as many as 70% of patients who have multiple myeloma, a cancer of plasma cells in the bone marrow, develop subsequent vertebral metastasis and pathological vertebral fractures (PVF).

As contemporary systemic therapies for multiple myeloma have come online, the life expectancy for those suffering from the cancer has dramatically improved. As patients live longer, repairing the disabilities associated with PVF and managing the pain it produces has become a high priority. The authors say the evidence indicated that balloon kyphoplasty and percutaneous vertebroplasty are effective treatments for multiple myeloma-related PVF, with no significant difference shown between the two procedures.

"Percutaneous vertebroplasty and balloon kyphoplasty showed significant pain and functional improvements in terms of analgesia requirements, Cervical Spine Function Score, Eastern Cooperative Oncology Group scale, EQ-5D score, Karnofsky score, Neck Pain Disability Index, Oswestry Disability Index, Short form-36 (SF-36) questionnaire and VAS pain scale," states the study. "Both procedures also reported promising radiographic outcomes in terms of vertebral height improvement, maintenance and restoration, as well as kyphotic deformity correction."

The study concluded that percutaneous vertebroplasty and balloon kyphoplasty are safe and effective procedures that offer pain relief, reduction in pain-associated disability and reduction of fracture incidence. It also says the two minimally invasive procedures are associated with low morbidity risk, making them viable options in frail patients.

The minimally invasive procedure can transform the lives of patients with chronic pain.

When conservative treatments for osteoporotic pressure injuries fail, balloon kyphoplasties can deliver lifechanging results for older patients doing everything in their power to stay active as they age.

Alfred Rhyne, MD, a spine surgeon at OrthoCarolina in Charlotte, says the procedure can provide patients with the freedom to enjoy their retirements in the ways they dreamed after years of escalating pain and frustration when immobilization, braces, physical therapy, anti-inflammatories and pain medication have failed to help them.

"I've performed about 2,000 balloon kyphoplasties over two decades, including one on a 103-year-old man who was able to resume his life of light yard work and regular walks," says Dr. Rhyne. "The procedure has helped him and many others continue to enjoy the lives they've worked hard for and deserve."

The addition of the balloon makes kyphoplasty safer and more predictable than vertebroplasty, says Dr. Rhyne. It often can restore some lost vertebrae height caused by a compression injury, which is important because added pressure to the vertebrae above and below the fractured bone that occurs when the height isn’t restored makes nearby levels more prone to breaking.

The balloon also creates a cavity into which polymethylmethacrylate (PMMA) is injected, allowing the surgeon to use PMMA with a higher viscosity. While the low-viscosity PMMA used during vertebroplasty can extravasate beyond the vertebral body, the higher-viscosity toothpaste-like PMMA that can be used with balloon kyphoplasty makes it easier for surgeons to achieve their goal of containing as much of the PMMA as possible within the vertebral body.

Instrumentation systems and the balloons themselves have improved over time, further improving outcomes associated with the once inpatient-only procedure that’s now routinely performed in ambulatory surgery centers and office settings. Patients undergo conscious sedation via propofol, and the percutaneous procedure takes about 30 minutes for each vertebrae level that is repaired, says Dr. Rhyne. Up to three levels can be treated per procedure.

"A broken spine sounds devastating, but because blood loss during a balloon kyphoplasty is minimal and the anesthesia is light, the procedure isn't traumatic," says Dr. Rhyne.