Is Outpatient Spine Right for Your ASC?

Neurosurgery-Spine Pain Management Orthopedics

By: Danielle Bouchat-Friedman | Senior Editor

Published: 9/26/2022

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Improvements in minimally invasive procedures combined with increased payer acceptance have bolstered interest in this specialty.


Spine surgery is steadily moving out of the inpatient setting and into surgery centers thanks to an increase in minimally invasive options, a reduction in costs and sky-high patient satisfaction rates. But it takes a specific set of skills for a surgery center to succeed in the outpatient spine space, according to J. Alex Sielatycki, MD, an orthopedic surgeon for Steamboat Surgery Center (Steamboat Springs, Colo.) who performs roughly 15 spine procedures a week. Here’s what you need to know if you are thinking about adding this growing specialty.

• Enlist expert help. Whether you’re adding spine to an existing service line or starting from scratch, there are going to be many opportunities to lean on experts for advice and help. Take full advantage. That’s just what Andreas Sauerbrey, MD, one of the founders and the current president of Steamboat Orthopaedic and Spine Institute (SOSI) did when Steamboat Surgery Center opened in 2019 in partnership with UCHealth. The guidance paid off in a big way. Instead of building a new facility, the leadership team chose to retrofit an existing building. “There’s always a little bit of compromise when you’re not designing from the ground up, and we got stuck deciding whether we should have two or three operating rooms,” says Dr. Sauerbrey. With limited space to work with, he leaned heavily on his architect for advice on what to do. For instance, the team chose to go with two ORs at around 400 square feet rather than two small ORs and a third even smaller OR, a move that ultimately improved a crucial element of their operations. “It helped us with patient flow, which is so important,” he says.

• Negotiate with insurers. Dr. Sauerbrey says private insurers have set contracts and agreements in place with different ASCs regarding the specific spine procedures that can be covered in an outpatient setting. However, Medicare has a more defined list of reimbursable spine cases for ASCs, a list heavy on non-instrumented lumbar procedures (decompressions) that also includes cervical spine operations.

It’s important to keep in mind that payer acceptance, something that is already high because of the inherent cost savings, will only increase as more facilities provide data on the effectiveness of outpatient spine surgery. “Doing these procedures in an outpatient setting can be substantially lower in cost, so payers are interested in having them done in a surgery center,” says Dr. Sielatycki. “The fee structures associated with outpatient spine surgery are often much lower, so payers have an interest because it saves them a lot of money.”

Be aware that delays in securing reimbursements during the start-up phase can occur, and insurers might also want to reduce your surgeons’ professional fees, which could vary greatly by region and center. “You must make sure your payer contracts are in place,” says Dr. Sauerbrey. “You can’t control government and insurance agencies and you could wait months before you can treat a patient with a specific type of insurance. Make sure you understand, before opening, how long it will take between performing cases and getting paid.”

• Recruit top talent. The spine surgeries done at Steamboat Surgery Center are cutting-edge, and while the right equipment and technology plays its part, success ultimately comes down to the surgeons. “Our surgeons are extremely well-trained and are using the latest equipment,” says Dr. Sauerbrey. He recommends working with surgeons who are comfortable using a variety of techniques and implants when they operate. “We could purchase different spine tables, a different C-arm or a different microscope, but the surgeons must be comfortable performing minimally invasive procedures in an outpatient setting while obtaining successful outcomes.”

UNDER THE MICROSCOPE Dr. Sielatycki performs a range of minimally invasive spine surgeries such as laminotomies, foraminotomies, diskectomies and cervical disc replacements.

• Expect non-instrumented cases. Most of the less-invasive outpatient spine operations Dr. Sielatycki performs are non-instrumented, an umbrella term for decompressions, procedures that relieve pressure caused by one or more compressed nerve roots on the spinal column. “If a patient has a one- or two-level nerve root irritation, I can make a small incision and take the pressure off those nerves without having to implant anything,” he says.

Then there are conditions where the patient’s problem is more mechanical or structural. A patient might have a pinched nerve, but they could also be dealing with a slipped or shifting vertebra, which might require a spinal fusion. A spinal fusion requires implanting screws and rods and reconstructing the spine in a way to relieve pressure on the nerves. Dr. Sielatycki says the downside of this procedure is that it can potentially accelerate breakdown of discs above or below the site of the fusion.

• Invest accordingly. Performing complex fusion or disc procedures in the outpatient setting requires investing heavily in costly technology and equipment. “The standard or classic technique is using a fluoroscope or a C-arm to take X-rays to perform minimally invasive placement of replacement discs or pedicle screws,” says Dr. Sielatycki. More recently, he says, newer technology such as navigational systems and robotic platforms allow for guided placement of hardware. Combining the precision this navigation and robotic technology affords with newer pain control methods ultimately allows for more procedures to be done in surgery centers. “With some of the newer techniques, particularly pain control methods, I can safely perform spinal fusions and disc replacements in an outpatient setting for more patients,” says Dr. Sielatycki. “A big part is the multimodal pain medications around the time of surgery, both before and after. Local injections of pain medication in the tissues and around nerves can help patients be much more comfortable immediately after surgery and help them go home more quickly.”

Another crucial piece of equipment for outpatient spine is a good surgical microscope, a tool that Dr. Sielatycki relies on to tackle minimally invasive procedures such as a laminotomies, foraminotomies and diskectomies. “The surgical microscope allows surgeons to make smaller incisions, but still see what we need to see,” he says.

Surgical microscopes have a big base that is firmly anchored to the floor and an arm with a viewing portal at the end of it. This arm is wrapped to keep it sterile and guided right over the patient by the surgeon. “I localize the surgical site with X-rays and make a small incision,” says Dr. Sielatycki. “Then I use tubular retractor systems designed for minimally invasive techniques, which offer direct visualization of the operative field and minimize soft tissue dissection and soft-tissue disruption.”

Placing sequentially larger tubes provides a viewing corridor from the incision all the way down to the spine for Dr. Sielatycki and then, with the microscope, he can look through the small corridors and magnify the view without needing to make a big open incision. “The microscopes are lighted, which helps me see down into the small holes that I am working through,” he says. “You can get a nice bright light and a big view of what you’re working on, even though it’s through a small incision.”

Include Spine Surgery Alternatives
CONSERVATIVE APPROACH
MULTIPLE OPTIONS J. Alex Sielatycki, MD, performs nearly 800 spine surgeries at Steamboat Surgery Center each year, but patients have a variety of more conservative options for their pain as well.  |  Elisa Maines Photography

Surgical facility leaders who are interested in adding outpatient spine must understand that surgery is almost always the last resort for patients — and position themselves accordingly. In fact, only about 10% of patients seen for spine complaints benefit from some type of surgical intervention, according to J. Alex Sielatycki, MD, an orthopedic surgeon who performs nearly 800 spine surgeries each year at Steamboat Surgery Center in Steamboat Springs, Colo.

Dr. Sielatycki’s patients have generally exhausted a series of less invasive options before eventually opting for surgery. “Most adults, at some point in their lives, will have some type of back, neck or low back pain, but the majority of those people will not require surgery for treatment,” he says.

His patients don’t come in and immediately get booked for surgery. Instead, they first see Brian Siegel, MD, an anesthesiologist at the facility, who specializes in the areas of interventional pain management and regenerative medicine. He offers patients several more conservative treatment options — including diagnostic and therapeutic nerve blocks, epidural steroid injections, spinal cord stimulator implants and regenerative medicine treatments. The goal is to see if patients can get relief without surgery. “We like to try and manage their pain with conservative therapies in the beginning and with anti-inflammatories, physical therapy and stretching,” he says. This is often an effective approach, as only a small percentage of patients with back pain ultimately need to have something done surgically, according to Dr. Sielatycki.

— Danielle Bouchat-Friedman

The least-invasive way

There are multiple factors driving current demand for outpatient spine, including a growing pool of candidates. “Patients who are in overall good health and don’t have major comorbidities are able to undergo procedures in an outpatient setting, and they prefer it,” says Dr. Sielatycki. “Patients find it easier to navigate a smaller outpatient center than a large hospital, and most patients would rather recover at home after surgery.”

COVID-19 has also played a key role. “People still have real fears about acquiring an infectious disease in a hospital setting and feel much more at ease in an ASC,” says Dr. Sielatycki. No matter where patients decide to have their operation, Dr. Sielatycki says that the number one goal is to give them the best possible outcome. “When you’re looking at indicated spine surgery, the goal is to do it in the least invasive, most durable way,” he says. Increasingly, facilities are proving that can be accomplished in an outpatient setting. OSM

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