Brian Durkin, DO, is medical director of the Pain Institute of Long Island in Port Jefferson, N.Y., and is president-elect of the New York State Society of Interventional Pain Physicians. Here, he shares his thoughts on outpatient pain management.
Q: Are there any overarching trends or advances you're seeing now in outpatient pain medicine?
Dr. Brian Durkin: I've always said that over the years the other surgical specialties have gotten more minimally invasive, from laparoscopic, to robotics, to decrease the wound size and improve the patient's outcomes, except for spine surgery. Spine surgery is still done with big, open wounds, and the drive toward minimally invasive stuff is just starting to occur, I think, in spine surgery, but it hasn't gone like wildfire, like laparoscopy and robotic surgery has.
Q: So would you say that there's anything that spine can learn from other specialties and how to adapt to those more minimally invasive techniques?
BD: I think the training of upper spine surgeons, it has been mostly open surgery and doing things using the three dimensions that we use with the human eye. Where minimally invasive stuff with scopes and such rely on two-dimensional imaging along with fluoroscopy, which many a spine surgeons aren't facile with. And so I think the future training of spine surgeons and interventionists has got to be more two-dimensional focused rather than three-dimensionally focused. And then we can use smaller entry ports and [be] able to make a difference in patients with spine issues without having a big, open surgical wound.
Q: What would you say is the major driver for the shift toward minimally invasive and outpatient procedures?
BD: The government is really pushing to get things done less invasively with less hospital stays. In many parts of the country, total joints are done outpatient with a 23-hour stay in an ambulatory surgery center. I see that as a future for spine interventions as well, where people would stay a day or two in the hospital. And maybe through minimally invasive techniques we can get to the point where patients sleep in their own bed at night after a spine operation.
Q: What are some strategies on how ASCs or other outpatient settings can decrease opioid use in their patients?
BD: Well, the first thing you can do is make the wound smaller. Then, you don't have a big wound that causes most of the pain. Opioid minimization used to focus on the side effects of opioids being nausea and vomiting after surgery. Now I think the focus has shifted toward preventing a potential opioid addict after they've been exposed to opioids. So we try to minimize opioid exposure. And if you're going to do that, other medications and techniques need to be done using local anesthetics and other nonopioids adjuvants. Ketamine has got a good role, I think, in using for postoperative pain management in many patients.
Q: What kind of growth or headwinds do you see on the horizon for your practice?
BD: I think the more minimally invasive spine procedures becoming more of the standard. There's a procedure called the Intracept Procedure that I do on an outpatient basis. There should be a codes coming for that so it can be done in an ambulatory surgery setting, which focuses on a target that never before was really thought to be a pain generator. It's called the basivertebral nerve. And we can minimally invasively blate that nerve and cure some forms of chronic low back pain without doing a fusion.