What’s Driving Growth of ASCs in the Spine Market?

The broader trend of orthopedic procedures moving to ambulatory surgery centers (ASCs) has been accompanied by a noticeable uptick in outpatient spine surgery.

We spoke with Alok Sharan, M.D., Director of Spine and Orthopedics at NJ Spine and Wellness, to find out why spinal surgeries are moving to ASCs at an accelerated pace, and what players in the spine market should expect as this happens.

What is causing the shift to ASCs in the spinal market?

 Dr. Sharan: Several technical factors allow surgeons to perform outpatient spine surgery. One is the advent of minimally invasive surgical techniques, which have been evolving over the past 15 to 20 years. Of course, surgeons must be trained in new ways of performing surgery. It’s one thing to come out with a new technique, and another to make sure surgeons are trained to use it.

Although the use of surgical navigation is currently limited, it will increase in the future specifically because navigation technology allows surgeons to make smaller incisions. My colleague at Duke coined the term “surgical footprint,” which I really like. It means surgeons no longer need to make large incisions to access the spine. They can be more precise with their approaches and make smaller incisions to decrease the surgical footprint. I think the use of navigation technology has decreased the surgical footprint, which has helped shift more cases to ASCs.

My big push has been to use regional blocks instead of general anesthesia — what we call “awake spine surgery.” The technique involves avoiding general anesthesia in lieu of novel regional anesthetic blocks in the spine, which helps patients recover faster. We’ve shown with our data, which has been confirmed by multiple other surgeons, that transitioning from general to regional anesthesia in spine surgery results in a 50% reduction in post-op length of stay. It’s a tremendous reduction and means that a huge cohort of patients can undergo surgery on an outpatient basis. Collectively, minimally invasive surgical techniques, navigation and the use of regional anesthesia enable surgeons to perform outpatient spine surgery.

How does awake surgery impact post-op care?

Dr. Sharan: When we currently perform a single-level lumbar fusion, the average length of stay is 0.7 days. Half of the patients who undergo a single-level fusion go home the same day, and 70% to 80% of patients are off narcotics within three to five days. Exparel, made by Pacira, is essentially Marcaine wrapped in a fat capsule that dissolves over 48 hours. Marcaine typically lasts for eight hours and Lidocaine lasts for one or two, but by using Exparel as a regional block, we see that patients feel minimal pain for the first 24 to 48 hours after surgery.

That’s helped us minimize how much narcotic medication we give patients afterward, which allows them to mobilize sooner after surgery. It also limits the amount of narcotics they use, which of course minimizes some of the collateral damage of narcotics, including constipation, nausea and vomiting. Patients who aren’t in pain are active quicker, which ultimately is great for their recovery.

Why do patients prefer an ASC over a hospital stay?

 Dr. Sharan: I think cost of care is a significant issue. Many insurance plans force patients to bear more financial risk. So, patients are looking for ways to have their surgeries done without having to pay a lot. Because the cost of care is lower in ASCs than in hospitals, patients want their procedures to be performed in an ASC. Some insurance plans are also encouraging patients and surgeons to schedule surgeries at an ASC instead of in a hospital.

What tools, resources and processes are needed to support the movement of cases to ASCs?

Dr. Sharan: Instruments that allow surgeons to perform minimally invasive surgery are essential and surgical navigation platforms provide additional benefits. What’s more interesting, though, is the influx of technology companies that are developing software platforms that guide patients through a series of pre-hab exercises to get them stronger before surgery or inform them how to manage nutrition or smoking issues leading up to their procedures.

Tremendous startups and established companies are creating software to engage patients before surgery. At a high level, these patient engagement software companies, which aren’t necessarily traditional medical device manufacturers, are playing an increasingly critical role in the movement of spine cases to ASCs. One thing that gets lost in the discussion about outpatient spine surgery, which I’ve learned with my awake surgery protocol and through years of experience, is that the preoperative component of patient care is critical. How surgeons talk to the patients, educate them about their procedures and prepare them for surgery with prehab exercises and optimized nutrition are critical to success in outpatient spine surgery.