Four spine leaders answer four questions on how spine surgery will develop at ASCs:
Question: What do you see as the next big trend in spine for ASCs?
Daniel Lieberman, MD. Phoenix Spine & Joint: Over the last five years we've seen real energy pulling away from deformity correction and multilevel fusion surgery, and the entire field of spine surgery moving into much more focused interventions based on structure. I think the next horizon is focused interventions based on symptoms. What patients really are concerned about is their pain. Our surgery centers offer endoscopic dorsal rhizotomy, so ultra-minimally invasive surgeries that eliminate pain are really the next horizon. It's almost like we're going to see spine surgery absorb and move into more of a pain management approach, rather than a structural correction approach.
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Q: How do you see spine and ASCs changing in the next three years?
Kenneth Nwosu, MD. Neospine (Puyallup, Wash.): I see endoscopic spine surgery becoming the standard of care for spinal decompression. We will be able to perform a decompressive surgery through an incision less than 1 centimeter safely and as effectively as open spine surgery. It's a no-brainer. In my perspective, I see that being a standard of care for most providers and I think that will be the expectation by payers and patients as well.
Secondarily, I see most spinal surgeries including complex fusion moving to the ambulatory surgery center. I would say the rate limiting step to transitioning all spine care would be those patients who are severely ill and those who have significant comorbidities like a significant cardiac history or a history of high opioid use. Lastly, as a result of all this spine care volume being transitioned to the ASC, I continue to foresee emerging spinal technologies like robotics and augmented reality becoming available in the ASC as well.
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Q: What sort of competition do you expect from hospitals as outpatient spine surgery becomes more widely adopted?
Vladimir Sinkov, MD. Sinkov Spine Center (Las Vegas): Hospitals have been expecting this trend to come for a while. What is interesting is how it has slowed down innovation. For example, I approached a hospital in Las Vegas about purchasing a robot to perform minimally invasive spine surgery and increase volume at that hospital. But they expect to lose so many elective spine surgery cases over the next five years to ASCs and expect very little cases to be done in the hospital, so they didn't want to invest in the technology. That's somewhat of a defeatist attitude that I've seen some hospitals take.
Other hospitals are investing in surgery centers so they can secure some profit from the partnership. Hospitals still have a lot of capital they can invest, where surgery centers are typically starved of capital, which is why it makes sense to partner. In my opinion, outpatient migration of spine surgery will encourage surgery centers to rent or purchase surgical robots and other advanced technology to drive that exodus even faster.
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Q: Do you see more surgeons adopting endoscopic techniques as spine procedures continue to migrate to the outpatient setting?
Saqib Hasan, MD. Webster Orthopedics (Oakland, Calif.): I think the migration to endoscopic procedures is just one component of the larger shift to the outpatient setting. This move is largely facilitated by more surgeons utilizing minimally invasive techniques and leveraging technologies to provide reliable outcomes and faster postoperative recovery. However, most simple decompression surgeries are typically already done as outpatient procedures. The move toward endoscopic spine surgery is more intuitive — if you can utilize a 7 mm camera to achieve equivalent or superior outcomes compared to current standard techniques, the question becomes, "Why wouldn't I use endoscopic techniques?"
Many surgeons themselves would likely prefer receiving an endoscopic discectomy over a standard microdiscectomy — I know I would. Numerous randomized-controlled trials have shown the significant benefits of endoscopic techniques in the context of less postoperative pain and faster recovery, which lends to the wider trend toward the ambulatory care setting.
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