The Growing World of Same-Day Spine

New technologies and techniques expand what is possible today.

Same-day spine surgery is having a moment right now. From cervical disc replacements to thoracic decompressions to microdiscectomies and more, ASCs across the U.S. are performing spine surgeries that had been traditionally reserved for inpatient hospital environments and sending patients home the same day.

Convergence of factors

The move to an outpatient setting for many of these spine procedures has been occurring steadily thanks to a combination of advancing technologies, new minimally invasive techniques and superior pain control protocols. Then the COVID-19 pandemic came along and upped the ante.

“The pandemic really helped to solidify that both patients and physicians often want to avoid the hospital for elective spine surgery,” says Nick Jain, MD, orthopedic surgeon at DISC Sports & Spine Center in Newport Beach, Calif. “There’s always been an interest from a surgeon standpoint since there’s the potential for faster recovery times and less blood loss through minimally invasive techniques. However, a lot of people were scared to enter hospitals for fear of contracting COVID — that helped to push things even further.”

Technique and technology advances

The pandemic notwithstanding, the current same-day spine surge wouldn’t have been possible without certain changes. “Each procedure has undergone an evolution in technique to allow outpatient work to thrive,” says Dr. Jain.

Dr. Jain says the outpatient spine procedures now offered at DISC include cervical artificial disc replacement, cervical foraminotomy, anterior and posterior cervical and lumbar fusions, thoracic decompression, microdiscectomies, lumbar decompression, single and multilevel fusions and more.

Many of the procedures Dr. Jain cites were able to migrate from inpatient hospital procedures to same-day outpatient surgeries thanks to new technology and techniques. “We can do an anterior lumbar interbody fusion in an outpatient setting now,” says Dr. Jain. “Ten years ago, that wasn’t possible.”

While there are multiple factors behind the popularity of outpatient spine surgery, it’s the marked technological and research advances that have really increased its feasibility, says Wesley M. Durand, MD, orthopedic surgery resident at Johns Hopkins University in Baltimore. The biggest has been the move toward minimally invasive surgery. “Minimally invasive spine surgical approaches tend to decrease near-term pain and blood loss, thus allowing for quicker perioperative recovery,” says Dr. Durand.

Microscopic techniques have indeed propelled outpatient spine in recent years. Reliance on minimally invasive techniques to perform procedures such as decompressions, fusions, laminectomies means facilities must invest in reliable surgical microscopes, says Dr. Jain. The microscope allows the surgeon to make small incisions but maintain a clear view of the patient’s anatomy. “Previously, there was a lot of the spine that had to be exposed with the muscle pulled back to do these procedures,” says Dr. Jain. “But with percutaneous and MIS, we can go through the muscle and have less postoperative pain and blood loss. That’s been critical to the success of outpatient spine.”

Improved implants

CRITICAL VIEWPOINT To run an efficient spine program, ASCs must invest in a reliable surgical microscope that allows surgeons to make small incisions while maintaining a clear view of the patient’s anatomy.   |  DISC Sports & Spine Center

Another major area of improvement: the advancement of artificial disc replacement as an alternative to a traditional fusion for degenerative disc disease or disc herniation. Though this procedure isn’t new, advances in implant technology now make them longer-lasting and safer, leading to improved recovery times and more efficient surgeries.

For instance, says Dr. Jain, anterior cervical fusions were previously done with a bone graft and an interbody cage with a plate and screws on top. “How those plates sat led to more swallowing issues and neck pain and stiffness for patients after surgery, and they had to be immobilized in a cervical collar afterward,” he says, adding that a combination of factors has improved outcomes and reduced post-op issues. “The microscope and smaller instruments have led to anterior cervical arthroplasty being an option, which requires no immobilization, less post-op dysphagia and less neck pain and stiffness in general,” says Dr. Jain.

Long-suffering patients are the ones who often wind up benefitting most from the growth of the same-day spine trend, not only in terms of faster recoveries but also due to greater options. “There was a time not long ago when spinal fusion was the only surgical option for degenerative disc disease or disc herniation,” says Dr. Jain. “Now, thanks to advances in technology and techniques, disc replacement surgery is a safe and effective outpatient procedure for many with chronic pain.”

Efficiency through ERAS

Finally, Enhanced Recovery After Surgery (ERAS) protocols are making outpatient spine surgery possible, says Dr. Jain. Premedication with a non-narcotic cocktail often containing acetaminophen, gabapentinoids and NSAIDs have helped decrease patient pain and nausea postoperatively, which generally leads to faster ambulation and quicker discharge times.

At DISC, surgeons typically also inject a local anesthetic at the surgical site and combine oral narcotics with an anti-inflammatory and muscle relaxants to relieve post-op pain, allowing patients to ambulate within hours of a procedure, which Dr. Jain says helps to speed up the recovery process.

Patient selection is paramount

While techniques and tools have boosted the number of outpatient procedures that can be done at an ASC, an increasingly wide net is also being cast for patients who are good candidates for same-day surgery.

“We’re getting better at managing patients with comorbidities,” says Dr. Jain. “We have enhanced optimization preoperatively with overall better screening processes for potential failure, ensuring patients have adequate family support and are free from certain medical comorbidities so there aren’t issues postoperatively.” Those limitations include severe cardiac or pulmonary comorbidities, morbid obesity, active injections or complex vascular problems. That said, there are plenty of strong candidates out there. “Those who can go up and down a flight of stairs can often safely receive spine surgery in an outpatient setting,” says Dr. Jain.

Ultimately, patient selection is paramount for the success of same-day spine, and it’s up to providers to do their due diligence. In a study co-authored by Dr. Durand looking at emergency department (ED) visits after outpatient surgery, the researchers note, “Appropriate patient selection is critical for successful ambulatory spine surgery.”

Specifically, Dr. Durand and the other researchers found that the rate of visits to the hospital after outpatient spine surgery was roughly 9%, which he notes is fairly high. They found that female patients, patients with more comorbidities, patients undergoing surgery at hospital outpatient departments and patients less than 40 years old had increased odds of multiple post-op ED visits.

“Some of the most common reasons for post-operative ED visits were back pain, chest pain, shortness of breath and gastrointestinal complaints (constipation, nausea, vomiting),” says Dr. Durand, noting that many of these issues can be remedied with hospital admission. “Acute postoperative pain can often be mitigated via medication optimization, preoperative expectation-setting and availability of on-call support for pain management,” he says.

Constipation is a prime example. Dr. Durand notes it often can be prevented by use of laxatives, and educating patients on what exactly to expect prior to their procedure can address concerns that may happen postoperatively. To help reduce less likely complications, he recommends a multidisciplinary approach. “Successful adoption [of outpatient spine procedures] will depend on a team of OR staff, anesthesiologists and surgeons who are intimately familiar with the surgical characteristics and risks specific to spine surgery,” says Dr. Durand. “Contingency planning for evaluation, triage and management of potential perioperative complications is essential, including established protocols for transfer to a higher level of care, if indicated.” Some centers, he adds, elect to establish extended care protocols, allowing patients a prolonged period of observation in the ambulatory care setting for perioperative recovery.

“In the end, ED evaluation of certain acute post-operative complaints — such as chest pain and shortness of breath — is appropriate,” says Dr. Durand. “The availability of timely medical evaluation of certain particularly concerning postoperative symptoms will remain central to conducting safe outpatient surgery.”

As this service line continues to move from hospitals to ASCs, safety must remain the top priority. OSM