March 25, 2019

Today’s Outpatient Spine Surgery: Micro-Discectomies to Multi-Level Lumbar Fusions

By Jeffrey R. Carlson, MD

Most physicians understand the outpatient revolution in some areas of orthopaedic surgery, especially in Sports Medicine.  However, many still believe that spine surgery is strictly an inpatient procedure, often requiring extended patient stays.  But, that too has changed dramatically.

In 2018, approximately 50% of the spine surgeries performed nationally will be done on an outpatient basis.  In my surgical practice, 90% of spine surgeries are done on an outpatient basis, where the patient is discharged from the recovery room to go home; 5% are completed under 23 hour observation and only 5% are truly classified as inpatient.  I expect outpatient spine surgeries will soon be 99% of the procedures I perform.  There are many reasons for this change, which I list here:

Surgical Innovation – Advancements in minimally-invasive surgical technique, instrumentation, surgical approaches, anesthesia, intraoperative blood salvage, and training have allowed complex spine procedures to be moved to the Ambulatory Surgery setting.

Post-surgical Pain Management – Surgeries with smaller incisions and better technique cause less trauma to the patient, typically resulting in less post-surgical pain. Better, shorter-acting anesthesia allows the patient to wake up quickly after surgery and be discharged. Improved intraoperative and post-surgical pain management techniques, and use of multi-modal drug therapy, which relies less on narcotics and more on a “cocktail” of analgesics, neuropathic agents, muscle relaxants and antidepressants, provides vastly better pain control for patients after surgery.

Cost – Outpatient vs. Inpatient – Costs for inpatient spine surgery average about five times more than for outpatient spine surgery.  This average can fluctuate, based upon hospital and procedure, but is fairly consistent.

Patient Satisfaction – Patients like being at home, and recovering from surgery is no exception.  They sleep in their own bed, eat their own food, and don’t have to share a room with a stranger while they recover. I send in specially-trained home health nurses and Physical Therapists if the patient needs at-home care. At the hospital, patients may or may not have a private room, have to eat hospital food and are constantly woken by nurses, checking vitals or by beeping monitors.

Hospitals are full of really sick people.  My patients aren’t sick; they are having spine surgery,  but they may pick up MRSA or C-Diff if they are made to stay inpatient after spine surgery and the odds increase the longer they stay.  Having outpatient surgery avoids that complication.

Efficiency – ASCs are efficient and surgeries typically run on time.

Pre-surgical Screening – Comorbidities are caught and addressed before outpatient spine surgery.  If not resolved, we go inpatient or not at all.

Outcomes – In the years that I have been doing outpatient spine surgery, the results have been incredibly positive; rarely do patients have post-surgical complications requiring hospital admission, and almost all post-surgical issues can be managed by the Home Health nurse or by me, over the phone or in the office.

If patients express some trepidation about their recovery, are afraid of post-surgical pain or that they will suffer a complication if they aren’t in a hospital, we talk in detail about these concerns and how they are handled.  After recovering, they often marvel at the entire experience of outpatient surgery — its ease, efficiency and mostly importantly, the resulting improvement in their quality of life.

Jeffrey R. Carlson, MD is the President and Managing Partner of Orthopaedic & Spine Center in Newport News, VA. He holds a fellowship in Orthopaedic Trauma surgery and a combined Neurosurgery-Orthopaedic fellowship in complex spine surgery from Brigham and Women’s Hospital in Boston.