Anthony Giuffrida, MD, is the director of interventional spine and sports at Cantor Spine Institute in Fort Lauderdale, Fla. Here, he shares his thoughts on the future of outpatient spine surgery, and the technology he's excited for on the horizon.
Note: Responses have been lightly edited for style and clarity.
Question: What procedures do you think have the potential to migrate to the outpatient setting?
Dr. Anthony Giuffrida: I think we're seeing a big push from most procedures to outpatient if possible. And the factors that are contributing to that are better procedures, shorter procedures, less blood loss, less invasiveness, which allows us to let patients go home the same day. Total knee replacements used to be a three-day hospital stay, about 10, 15 years ago. Now patients are going home either the day after or the same day, and that's because we're doing a better job of the anesthesia and the procedure itself. We're using smaller, less invasive holes which results in less blood loss. This means patients don't have to spend as much time recovering.
With almost every type of minor orthopedic procedure, patients can go home the same day. Even spine surgeries now, if it's only one or two levels, patients are able to go home the same day. Every patient I treat as a pain management physician goes home the same day.
One thing that sometimes you need to take into account is if patients have support at home. If patients are alone and don't have much support, maybe it's not the best idea to send them home after spine surgery the same day. Then you need to look at their comorbidities; if they have heart disease, or lung disease, or some other issues that may hinder them from being able to rehab themselves. Every patient is different. But our goal is to get patients home as quickly as possible but still as safely as possible.
Q: Is there any advice you would give to surgeons that want to start doing cases outpatient?
AG: The number one thing that I tell anyone doing procedures is to always have the patient in mind first. Don't try to do things outpatient that you don't feel comfortable with. You have to be smart about the patient selection. You want to have a young healthy patient versus an elderly unhealthy patient in the outpatient setting. And as you do more and more outpatient procedures, your comfort level will go up.
At Cantor Spine, we prep our patients differently. We put them on a special diet so that they'll heal faster. We make sure their BMI is a certain amount. Being overweight, being on a bad diet and smoking are going to cause patients to have problems either during surgery or immediately after. If we can mitigate those three issues, then we can send patients home the same day.
Q: What are the key elements to your practice's success with spine patients?
AG: So for us, the number one thing is doing the right procedure for the right patient. We don't try to squeeze a round peg into a square hole. We know what the patient needs and we're able to do that. We're not just good at one thing where we try to make every patient undergo our procedure. We perform the procedure that the patient needs. Personalized medicine is here, but not everyone is trained in all different types of procedures; our ability to provide multiple levels of care makes our outcomes so good.
Q: What are the biggest challenges you're facing in spine today?
AG: Picking the right patient is first. And then secondly is you need to be confident in your skills. You need to know what you're doing, and you need to really know the anatomy before you decide to do that. There's a lot of important structures in a small area, which is what I tell patients. It's not like we can just do a knee replacement, by taking out the spine and putting a new one in. You have to work in small spaces around very important structures. So, the risk of something going awry is higher than some other surgery.
Q: What outpatient spine trends and technology are you currently most excited about?
AG: We do the Intracept procedure where which would've included a two to five day stay in the hospital for patients. Now it's a 45 minute to two hour procedure where patients go home within an hour and a half after the procedure. The VertiFlex procedure used to be a one or two level fusion for stenosis. We now can put a little spacer in the back in 45 minutes and use one or two staples to close up the incision. And the patients go home the same day and do great. I have to keep my patients from doing too much one or two days after the procedure. It's not like they're down for six weeks after a big surgery.
With minimally invasive procedures, we can give the patient the same amount of relief without major surgery. I tell patients it usually takes them longer to recover from the anesthesia than it does from the actual pain of the procedure.
Q: Any final thoughts?
AG: The ASC is where medicine is going. The cost of being in the hospital is just too great to sustain. A three-level fusion and a few days in the hospital costs the healthcare system upwards of $70,000 to $100,000. A three-level Intracept procedure will cost $10,000 to $15,000 in the outpatient setting. We're cutting costs in the ASC by over 50 percent. If we can make the process easier and less painful for the patient, and decrease cost, that's a win all around.
There's going to be a huge push for outpatient surgery the next five years, and we're going to see great things from it. The one thing we have to remember is we have to keep safety in mind always. You have to pick the right patients. You can't have everyone go to the ASC.