Not too long ago, patients in need of complex spine procedures would find themselves wandering through sprawling hospital complexes for surgeries and follow-up appointments.
That experience is now happening less frequently for many individuals, however, as the types of spine surgeries that once only took place in traditional acute care hospitals shift into the ambulatory surgery center (ASC) setting. The trend is likely to continue, too, according to ASC executives who specialize in spinal treatments.
“[Patients like that they don’t] have to park in a huge parking lot, catch a shuttle to the hospital, go through outpatient registration, and then proceed to the new hospital for surgery,” Dr. Arthur Valadie, a board-certified orthopedic surgeon and physician president for Coastal Orthopedics, told ASC News.
The Florida-based Coastal Orthopedics operates an ambulatory surgery center that specializes in spine and joint surgery. There are many benefits to performing minimally and advanced spinal procedures in an outpatient setting, both for the patient and the health care system, Valadie said.
But one of the most common ASC perks patients reference is that improved experience, he said.
“They come back to the front door, head upstairs, check in at the surgery center for operation,” Valadie said. “They can sleep in their own bed that night.”
As for broader implications for the health care system, ASCs often offer significant cost savings. For example, a laminectomy in an ASC in 2022 cost around $812, according to online Medicare pricing data. The same procedure’s cost at a hospital: $1,480.
“When a payer reimburses a surgery center, it’s typically at a discounted rate compared to a hospital,” Dr. Michael Burdi, an orthopedic spinal surgeon with Community Orthopedic Medical Group and California Specialty Surgery Center, told ASC News.
Located in Mission Viejo, California Specialty Surgery Center is one of Four outpatient orthopedic and spine surgery centers within Hoag Orthopedic Institute.
Cost effectiveness, coupled with patient satisfaction, technological innovations, and legislative changes have made it possible for more minimal and advanced spinal procedures to take place in ASCs.
While this trend has accelerated in recent years, it didn’t always have such momentum.
History of spinal procedures in an outpatient setting
In the past, outpatient surgery centers primarily handled minor procedures like arthroscopies and interventional procedures.
However, advancements in technology and changes in regulatory policies, particularly those by the U.S. Centers for Medicare & Medicaid Services (CMS), have allowed for more complex surgeries, such as multi-level lumbar fusions and lateral procedures, to be performed in ASCs and other outpatient settings.
“There are many economic forces that have changed,” Burdi said. “For example, CMS, the provider and overseer of Medicare, has had some inpatient-only codes. Procedures that were typically considered to be done only in the hospital have been allowed to be done in the surgery center. It has been a process; it did not happen overnight.”
Notable changes include the inclusion of certain spinal fusion procedures and spinal cord stimulation implantation in the list of covered outpatient procedures.
As of this year, some specific spinal surgery codes now approved for outpatient settings include:
– CPT Code 22853: Insertion of interbody biomechanical devices with fusion
– CPT Code 22854: Insertion of intervertebral biomechanical devices (synthetic cage) with fusion
– CPT Code 22859: Total disc arthroplasty (artificial disc)
Additionally, many surgeries once required hospital stays, but due to technological advancements making surgeries less invasive and CMS gradually approving outpatient codes for such procedures, several are now done in outpatient centers, Burdi said.
“Laminectomy, for example, which involves decompressing the spinal cord or dura below the spinal cord, was typically done only in hospitals,” he said. “Thirty years ago, nobody would have considered doing it at an outpatient center. Gradually, CMS started allowing those codes there. A few years later, instrument fusions, such as putting metal or pedicle screws into the spine, became possible.”
Dr. Luke Macyszyn, a neurosurgeon with California-based DISC Sports & Spine Center, echoed these sentiments.
Key improvements to spinal surgery tech include specialized retractors that minimize tissue damage and advanced navigation systems, sometimes robotic, that enable precise implant placement through small incisions percutaneously, Macyszyn told ASC News.
Intuitive’s da Vinci, Johnson & Johnson’s Ottava, Stryker’s Mako and Moon Surgical’s Maestro are just some of the robotic systems that have transformed surgeries.
Overall, the market for robotic surgery technology is expected to expand from $18 billion in 2024 to an estimated $83 billion by 2032.
“If you perform an open muscle dissection, you can’t discharge patients home a few hours later,” Macyszyn said. “If you perform a percutaneous fusion with the use of some of these modern technologies, you’re able to keep muscle irritation and dissection to a minimum, allowing you to perform these complex spinal fusions and still discharge the patient home.”
‘Focus factory’
There are numerous benefits of performing spinal surgeries in a specialized center compared to a hospital setting, Macyszyn said. One key advantage is the specialized focus of ASCs.
In his center, the staff, including nurses and physical therapists, are exclusively trained in spinal surgeries, ensuring a higher level of expertise and consistent care. Unlike hospitals, where the same staff might handle a variety of unrelated procedures, the dedicated focus at ASCs leads to better patient outcomes and more efficient recovery processes.
“Hospitals, understandably, have to handle a wide range of medical issues and cannot be as hyper-focused on one area of medicine,” he said. “In our ASC, we don’t have to jump through hoops to change equipment between cases or manage various skill sets. We excel at one thing — spine and orthopedics — at a very high level.”
Additionally, the nursing-to-patient ratio at ASCs is significantly higher, with two to three nurses per patient postoperatively. This high level of attention enables patients to start their recovery almost immediately, such as walking to the bathroom just half an hour after surgery.
This intensive care not only improves patients’ psychological well-being but also reduces their need for pain medication and accelerates their short-term recovery, allowing them to go home sooner, he added.
Valadie likewise highlighted this point, adding that ASCs are a “focus factory” environment.
“You perform a limited variation of procedures, so everybody understands that,” he said. “Everybody’s good at it. You get a lot of repetition. So that hyper-focused approach, I think, is good for patients. A hospital sort of has to be all things to all people, whereas a specialty hospital or a surgery center can be more focused, and we only do orthopedics here.”
Surgical outcomes
Janet Carlson oversees the strategic development, construction and operation of new surgery centers across Kentucky, Indiana and Illinois with Commonwealth Pain & Spine.
Preparation and proper equipment are crucial for ensuring patient safety and successful surgical outcomes in her facilities, she told ASC News. Staff training is also critical, she added, specifically identifying advanced cardiac life support.
“That’s a requirement for me to ensure patient safety,” Carlson said. “If we ever have to … assist the patient with an unexpected outcome — though that’s not frequent at all — it’s better to be safe than sorry. Always be prepared.”
Progress in advanced imaging equipment has also accelerated the shift of spine procedures into the ASC setting, Carlson explained. Real-time imaging is vital during procedures, as it supports the precise placement of plates and screws.
Proper planning and budgeting for capital expenditures are necessary to acquire this equipment, which also includes surgical microscopes specific for spine surgeries.
For ASCs looking to expand into spine surgeries, the cost of doing so could vary greatly. Some considerations include how many ORs the ASC is going to run, and how many cases its orthopedic spine or neurosurgeons are going to bring in, Carlson said.
“You need to know how many surgeries they perform in a hospital setting or a hospital outpatient setting that could potentially migrate to your ASC,” she said. “You want to know their actual numbers over the last 12 to 24 months to see their actual CPT volume. This allows you to create a pro forma to project numbers, acuity levels, expenditure, training and staffing needs.”
Carlson recommended starting small and scaling up.
“We started with the smaller acuity procedures, where we did micro-discectomies and laminectomies, and that’s a good way to bring minimally invasive finesse to your ASC, is to start small,” she said. “Make sure everyone is comfortable, and that you have the proper preoperative anesthesia selection criteria and guidelines that you adhere to.”
Selecting patients and ensuring proper care
Carlson said that specialized tables and positioning devices, such as the Jackson table and Wilson frame, are essential for many spine procedures. Instead of using stretchers or recliner chairs, she recommended hospital beds for higher acuity spine cases.
“It’s a kinder, gentler way to take care of a patient postoperatively, to place [them] on a hospital bed,” she said. “It’s softer and it’s more comfortable for them after they’ve been on the table for a while and asleep and anesthetized.”
She also mentioned the importance of ensuring that surgeons are properly credentialed and have ample training time. This includes collaboration with vendors to support the education of clinicians on various procedures and implants, utilizing these partnerships to enhance training efforts.
“You need to have your folks prepared and trained ahead of time to manage the drain in a patient’s incision and know when to remove it before the patient goes home, among other things,” Carlson said.
All of the industry professionals ASC News spoke with said it is important to carefully select patients for surgery at ASCs.
Patients with multiple comorbidities or those at high risk for complications should not be brought to such centers due to their limited capabilities compared to hospitals, Burdi said.
For instance, his surgery center can keep patients overnight and often does, but it lacks facilities like blood transfusion, which hospitals can provide during emergencies. Therefore, the selection of patients is critical to avoid complications that would necessitate transferring the patient to a nearby hospital.
“You just have to use good judgment because it’s kind of a black eye on the surgery center if this is happening with any kind of frequency,” he said. “Obviously, you would not want to have a bleeding complication at the surgery center where, you know, emergent blood transfusions are needed, and you’re not able to give them, and you have to kind of package the patient up and transfer them to the hospital.”