Puyallup, Wash.-based outpatient spine ambulatory surgery center NeoSpine, where David Paly, MD, is an anesthesiologist, focuses on anterior cervical and lumbar surgery, but also occasionally perform posterior spinous process procedures.
"A lot of what we're doing is total disc replacements and PEEK cages in the anterior cervical region," says Dr. Paly. "We've done three-level procedures. In a few cases, we've done four levels."
The team of practitioners at the surgery center has worked together for more than 20 years, including Richard Wohns, MD — the spine surgeon who founded this practice and is a pioneer in outpatient spine surgery — and the nurse manager.
"We are comfortable with each other and we know each others' strengths and weaknesses, and we respect each other very much," says Dr. Paly. "Most of the people the nurse manager hires are also from the hospital system we've known for a long time. There are a small number of them, so we don't have the problems when new people are coming in and out all the time."
Additionally, the practitioners are all cross-trained to help with equipment turnover. Dr. Paly doesn't have an anesthesia tech turn over his machine; he does it himself. The head nurse also pitches in, working wherever there is a need.
"It's a highly efficient working environment as well," says Dr. Paly. "We don't have to duplicate staff. We operate with a streamlined group of people who work really well together. To me, that's critical and a big part of the reason I took this job. A hospital system is a hard place to work because people don't trust each other and there are too many managers. You aren't respected or known as an individual. That's the beauty of working in a small place — they know what you and your family are like and it's very comfortable."
Patients who are appropriately worked-up and selected for surgery can have success. There are several patient indicators of particular concern, including:
• Sleep apnea
• BMI
• ASA level
"But if you're only looking at these issues, you're missing the boat," says Dr. Paly. "You aren't doing yourself or your patient a favor. You need to individually evaluate them preoperatively and figure out whether outpatient surgery is appropriate or not."
The outpatient center can manage typically five or six cases per day, sometimes performing as many as seven or eight cases. It's important for the care team at the center to agree on patient selection to keep the schedule running smoothly.
"There might be a big group of surgeons and anesthesiologists, who are all good surgeons, but they have a different opinion on what makes a good candidate for surgery," says Dr. Paly. "In a small center were you are only working with one operating room, it's to everyone's benefit to have a limited number of practitioners who are on the same page."
The average case duration is one to two hours. Dr. Paly offers these eight quick tips for successful outpatient spine procedures:
1. Select the right patients who will be able to handle outpatient spine surgery with minimal risk.
2. Involve the anesthesiologist in the case right away to make sure the patient is a good candidate for outpatient procedures. Review the patient history as soon as possible with the anesthesiologist who will deliver the care so there aren't any surprises or cancellations on the day of surgery.
3. Provide appropriate patient education so they understand how outpatient surgery works and have the right expectations about postoperative pain.
4. Limit the number of practitioners so everyone knows each other and is comfortable working together.
5. Use preemptive antiemetic and analgesics as soon as the patient is taken back for their procedure. Dr. Paly uses Pepcid to make sure there isn't much in the patient's stomach by the end of the case. In addition, there are multiple other preemptive antiemetic and analgesics given including low-dose ketamine.
6. Avoid giving too much fluid to patients so they don't wake up with a full bladder or feel puffy.
7. During the procedure, Dr. Paly gives a very low dose of propofol infusion such that it does not prolong emergence, but it's a powerful antiemetic. They can be given in non-sedating doses.
8. The patients wake up very quickly and are made comfortable — but they won't necessarily be pain free at discharge. Limit nausea and vomiting as much as possible.
Dr. Paly also uses opioids, but cautiously. This is especially true for patients who may have taken opioids in the past. "These are relatively low stimulation procedures and opioids are a double-edged sword," he says. "I find the high doses at-risk of nausea and prolonged discharge. Intraoperative low dose ketamine dramatically lowers opioid requirements. All patients get a low dose lidocaine infusion and preincisional local anesthetics. We monitor the patient constantly to make sure they aren't over anesthetized."
When the procedure is complete, the patient wakes up instantaneously and then the nurse gives typically low doses of fentanyl for analgesia. The cervical cases are typically an hour long, but the center keeps patients for at least three hours to monitor their recovery.
Now there is a bigger opportunity to perform outpatient spine cases than in the past. In 2015, Medicare added several spine procedures to the approved payment list for ambulatory surgery centers. But, Medicare is a traditionally poor payer, so running a lean business and operating at maximum efficiency is important. And not all Medicare patients are a good fit for the ASC.
"There are some patients who are undergoing simple procedures, but their comorbidities don't make them appropriate for outpatient procedures," says Dr. Paly. "The biggest challenge is the tremendous number of patients on high doses of opioids preoperatively, or patients who are on suboxone. They block the ability to give appropriate anesthesia. Sometimes we even turn away young and relatively healthy patients because their opioids are difficult to mange."
For those patients who are on high opioid doses before surgery, Dr. Paly recommends a transition to methadone a week before surgery.
"Of all the complex issues with spine surgery, that's the most frequent one and it's a big problem depending on what region of the country you're in," he says.