A disconnect exists between healthcare providers and patients regarding the benefits of outpatient spine surgery, according to Michael Wang, MD, a neurosurgeon at the University of Miami Health System.
"Companies like Nordstrom or Target don't really need to market their products — people come in everyday wanting to buy something. But people don't really want spine fusion surgery," Dr. Wang said during a June 15 presentation at Becker's 16th Annual Future of Spine + The Spine, Orthopedic & Pain Management-Driven ASC Conference in Chicago.
This article is sponsored by Johnson & Johnson.
To remain successful, ambulatory surgery centers and spine practices must work to improve patient satisfaction and educate consumers on the benefits of outpatient spine surgery. Dr. Wang believes these organizations can use Enhanced Recovery After Surgery protocols to reduce procedure costs, shorten recovery time and standardize clinical outcomes, which will ultimately improve patient satisfaction and help facilitate spine surgery's shift to the outpatient setting.
ERAS 101
ERAS is a multimodal perioperative care pathway designed to accelerate patients' recovery after elective surgery. The practice represents a departure from typical perioperative care by replacing some traditional practices with evidence-based best practices. ERAS also outlines a more comprehensive care pathway, which covers a patient's entire surgical journey, according to the ERAS Society.
The approach started in Denmark in the 1990s and initially focused on colorectal surgery. While the use of ERAS has since expanded to other surgery types, there is still more room for adoption, according to Dr. Wang.
"Seven years ago, I'd go to a conference and not one surgeon would know what ERAS was," he said. "At that time, it was already overtaking general surgery and vascular surgery. But spine and orthopedics had zero penetration on this concept, and that's where we needed it the most."
A closer look at UHealth's ERAS program
UHealth collaborated with the ERAS Society to start one of the first ERAS programs in the world for spine, according to Dr. Wang. The health system's ERAS spine program focuses on four main procedural aspects:
1. Working channel endoscope. Surgeons regularly use endoscopes for orthopedic and joint surgeries, but the devices are not common tools for spine procedures, according to Dr. Wang. "The endoscope is very powerful," he said. "But in spine, it's not a general skill that's practiced for multiple reasons, including building codes and training [barriers.]"
However, Dr. Wang believes working channel endoscopes provide numerous clinical benefits to support a quicker recovery for spine patients. The devices allow surgeons to perform spine procedures, such as decompressions or fusions, through extremely small incisions, sometimes as little as 8 millimeters. Surgeons can also use the tools on any patient, no matter their weight. This capability allows heavier patients to undergo a less invasive procedure and go home sooner.
2. Anesthesia without intubation. "When we first started doing this, we encountered resistance from anesthesiologists," Dr. Wang said. The process requires anesthesiologists to be more engaged during surgery, but offers numerous benefits for both patients and providers, including a much more normal homeostasis and reduced neuromonitoring costs.
3. Small caliber percutaneous screws. Dr. Wang uses the DePuy Synthes Viper Prime system during his spine surgeries, which enables percutaneous pedicle screw placement without the need for guidewires, Jamshidi needles or pedicle preparation instruments.
The system eliminates issues associated with geography and real estate in the operating room, since it is shorter in length and therefore much easier to insert, according to Dr. Wang. Viper Prime also avoids issues with k-wire breakages or bending.
4. Multimodal pain management. Dr. Wang believes the key to UHealth's ERAS program was incorporating Exparel into its multimodal pain management strategy. Exparel, or liposomal bupivacaine, is a local, nonopioid analgesic administered during surgery to help control a patient's pain and reduce the need for postsurgical opioids.
"I tell patients spine surgery is intrinsically the most painful surgery there is, period," said Dr. Wang. "This allows you to have long-acting, regional analgesia … for about three days of coverage, which is really the critical time."
The Benefits of ERAS
Dr. Wang published a 2017 study highlighting the significant clinical and financial benefits associated with ERAS in the journal Neurosurgery.
For the study, Dr. Wang and colleagues compared acute care costs and patient outcomes for either conventional or ERAS-based minimally invasive transforaminal lumbar interbody fusion. ERAS was associated with a 15.2 percent lower overall care cost and a 2.7 day shorter length of stay. Patients treated with ERAS also experienced less blood loss — 68 cubic centimeters compared to 231 cubic centimeters for patients who underwent the conventional surgery.
"These ERAS concepts offer the opportunity for reduced OR time, reduced blood loss, reduced need for post-acute care hospitalization in a rehabilitation facility or skilled nursing facility and a lower overall procedure cost," Dr. Wang concluded.