Why Outpatient Spine Is Surgery’s Hottest Specialty

Neurosurgery-Spine Patient Experience Pain Management Industry Trends Anesthesia

By: Adam Taylor | Senior Editor

Published: 1/13/2022

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New techniques, better anesthesia and improved pain control make same-day back surgeries outstanding growth opportunities.


Less than a decade ago, virtually all spine surgeries were performed on an inpatient basis. The reason for this was much more than an antiquated belief that those who had just had back surgery should be immobilized for several days.

A single-level lumbar fusion was performed through a six-inch incision, during which surgeons used a saw saber to cut through muscles and could easily cause 1,000 ccs of blood loss. “No wonder patients needed to stay in the hospital,” says Dwight S. Tyndall, MD, FAAOS, a spine surgeon in the greater Chicago area. “The main reason they stayed is simply because of how bad they were hurting.”

Advances in surgical techniques, anesthesia treatments and postoperative rehabilitation have resulted in shorter procedures with less blood loss and lower risk for complications. These developments have allowed physicians to send once-skeptical patients home safely within 24 hours of their operations and at a lower cost that makes insurance companies happy.

A growing movement

“It’s a movement over the past seven or eight years that is gaining momentum every year,” says Alexander R. Vaccaro, MD, PhD, MBA, president of Rothman Orthopaedics in Philadelphia, a group that is planning a national expansion. “Patients, surgeons and payers prefer it. Everybody loves it, which is why spine surgery is the hottest topic in ambulatory surgical center circles today.”

The lightbulb went on for Dr. Tyndall about eight years ago, when advances saw him shaving inpatient stays from three days to an overnight observation. His evolution into minimally invasive surgical techniques allows him to perform microdiscectomies, anterior cervical discectomy and fusions (ACDFs), lumbar fusions in shorter periods of time and with fewer complications. “I was wowed by the improvements and thought that this was something I could replicate in an outpatient setting,” says Dr. Tyndall.

With appropriate anesthesia, appropriate pain control and a plan for appropriate rehabilitation, Dr. Vaccaro estimates that nearly two-thirds of all spine surgeries can be performed in an appropriately staffed ASC. For example, research shows that single- and two-level ACDFs are safe in an outpatient setting, as are some three-level ACDFs.

The main risks with ACDFs are dysphagia, the loss of the airway and being overly narcotized to the point of not being able to breathe properly, which is exacerbated by post-operative neck swelling due to the surgical procedure. Most studies show these potentially catastrophic complications usually occur in the first four to six hours after the operations. Therefore, says Dr. Vaccaro, they can be performed at outpatient surgical sites early in the day and patients can go home that evening after several hours of careful observation.

With lumbar fusions, the biggest danger areas are the length of surgery, the amounts of anesthesia administered and blood loss. Multiple studies have shown that single- or two-level fusion patients can be safely discharged within 23 hours as long as appropriate pain control is provided. “Advances in multiple areas have moved the needle toward the rapid migration of these procedures from hospital ORs to ambulatory surgery centers or hospital outpatient departments,” says Dr. Vaccaro. “Patient safety drove the train.”

Patient selection

INCREASINGLY COMPLEX Improved patient selection criteria and pre-op optimization continue to expand the kinds of spinal surgeries that can be done without the need for overnight patient stays.  |  Rothman Orthopaedic Institute

Rothman has developed multiple checklists for assessing swallowing, sleep apnea, airways and other factors to determine if a patient can safely undergo an outpatient ACDF. The providers also employ an intricate algorithm and navigational system to determine whether patients meet the health system’s clinical guidelines for identifying appropriate candidates for outpatient procedures. Navigators review the electronic medical records of approximately 2,200 patients a week. An artificial intelligence program is used to analyze patients’ height, weight, comorbidities, age, prior surgeries, smoking history and other characteristics. Patients are also asked a series of questions geared toward determining the level of social support they have at home on which they can rely for help immediately after the surgery. The results go into a computer program that designates patients as one of three colors:

• Green: The patient is approved for outpatient surgery. 
• Yellow: The patient has risk factors that might be modifiable. 
• Red: The patient is not a candidate for outpatient surgery.

The patient-selection methods Rothman uses can also help patients get on board with modifying their pre-surgical comorbidities, says Dr. Vaccaro. For instance, it’s possible to lower a patient from a physical status classification of ASA 3 (which identifies the presence of serious systemic disease) to ASA 2 (which indicates only mild systemic disease). When that’s deemed possible, the case is delayed until the patient improves to the point at which they can undergo outpatient surgery.

Dr. Tyndall says he won’t perform an outpatient ACDF on an otherwise healthy 45-year-old patient if their BMI is 40 or above. “It makes even minimally invasive approaches much harder simply because there’s so much more tissue to work through,” he says. “That means it’s going to be a longer procedure and therefore there will be more risks for complications, so it’s better to work with most of these patients in an inpatient environment.” 

Lumbar fusions, says Dr. Tyndall, can be performed safely in an outpatient setting on patients with BMIs as high as 50. He offers patients who are above that threshold the option of delaying surgery until they lose their excess weight. If they can’t or won’t, an inpatient surgery is scheduled. Dr. Tyndall says he always makes the effort to optimize his patients preoperatively, but a significant percentage of them smoke, drink and are slightly overweight. Results at optimization with these individuals are mixed and often aren’t good enough to tangibly improve their outcomes.

Dr. Vaccaro performs roughly a third of his surgeries in ASCs and many of his hospital patients are discharged within 23 hours. In total, he says, about 60% of his patients are home within 23 hours of their procedures.

For patients who aren’t comfortable or able to go home that soon, many ASCs affiliated with health systems are building Ritz Carlton-like recovery suites. Patients who need more time to recover are moved to a suite, where they’re observed by a nurse. The overnight stay costs about $250, much less than the $2,000 the same level of care would cost in a hospital.

“In addition to providing patients with extra comfort and saving money, it also allows us to treat more patients, such as those with varying ASA scale ratings whose cases might involve slightly higher complexities,” says Dr. Vaccaro. Rothman’s recovery suites, for instance, have increased the number of ASA 3 patients who can safely undergo surgery in the outpatient setting, a development that has decreased the inpatient population and saved the healthcare system significant money.

Anesthesia and pain control

CONFIDENCE ABOUNDS Better anesthesia techniques give surgeons the confidence to perform spine procedures in same-day settings with little fear that serious complications needing hospital transfers will arise.  |  Rothman Orthopaedic Institute

While advances in minimally invasive techniques, better percutaneous fixation systems, cortical screw techniques and other device improvements have helped speed up outpatient spine work, Dr. Tyndall believes anesthesiologists have been the most important component in the transition. “Sometimes a surgeon is only as good as his anesthesia team,” he says.

According to Dr. Tyndall, it’s crucial to have a team that is confident in transitioning from traditional gas inhalation anesthetics to IV anesthetics. A surgeon can’t be innovative and aggressive if the anesthesia provider hasn’t bought into the concept of outpatient spine and isn’t comfortable having a patient prone for two hours while surgeons do their work. “The IV anesthetics also allow patients to wake up without feeling groggy and out of sorts, which quickens recoveries and makes for fast and safe discharges,” says Dr. Tyndall.

To better control pain and avert over-narcotizing patients, Rothman replaces most opioids with alternative medicines — including IV acetaminophen, antibiotics that don’t depress the nervous system, gabapentin, pregabalin and steroids. The cocktails produce less sedation and allow patients to participate earlier in their rehabilitation, says Dr. Vaccaro. A similar mix of medications is used by Dr. Tyndall, who often also sends patients home with back braces and a cold compression unit that’s worn around the waist.

Regardless of the skills of surgeons or anesthesia providers, patients still play a vital role in the overall success of their surgeries. Some of Tyndall’s patients believe he suggests they undergo an outpatient procedure because he’s trying to save money at their expense. “That’s why it’s crucial to have a dialogue with each patient so they fully understand where you’re coming from,” he says. “The reason I’m passionate about outpatient spine is because it really benefits the patient in so many ways. They get a smaller incision, lose less blood, are under anesthesia for a shorter amount of time, recover quicker, go home sooner and experience less post-op pain.”

Most patients are receptive to the concept simply because the co-pays for an ASC procedure are significantly less than they are for an inpatient surgery, says Dr. Vaccaro. “Patients who are still resistant usually come around once you’ve explained the clinical benefits, why an inpatient stay is truly clinically unnecessary and how it’s not in their best interest to be in a hospital where the risk of contracting a post-op infection is much higher than at home.”

Dr. Vaccaro envisions more spine procedures moving to the outpatient environment in the years to come. “Hospitals should be tertiary and quaternary care centers where surgeons perform complex cases such as revision hip arthroplasty, scoliosis surgery, trauma cases, and tumor and infection procedures,” he says. “The trend for elective cases to be in an outpatient setting needs to continue. Only then will the healthcare system have more money to provide better care for more people.”

Dr. Tyndall agrees. He’s grateful to provide his patients with relief from chronic pain while gaining access with incisions one-third the size he used only 10 years ago. 
“I can’t tell you the last time I used a saw saber or the last time I actually had to order labs after surgery to check on a patient’s blood count,” says Dr. Tyndall. “It’s just not necessary anymore because the procedures have become so miniaturized that the amount of blood loss is miniscule.” OSM

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