By William Tobler, MD
When I tell patients that they can have their spine surgery done as an outpatient procedure, I can feel the atmosphere change. I can hear the relief in their voice and I see the warmth in their smile. A subliminal message has just been communicated: “Lumbar fusion isn’t so bad if I can have outpatient surgery and go home the same day.”
At the Mayfield Spine Surgery Center, one of the first free-standing outpatient centers in the Midwest, we have performed more than 15,000 surgical procedures since 2007. Our typical same-day surgery patient spends 90 minutes in the operating room and 150 minutes in the recovery room. Depending on the procedure, a patient whose surgery begins at 7 a.m. may well be home in time for lunch.
It is hard to believe that just 25 years ago some of these same patients were in the hospital for five days. We began turning that process upside down in the 1990s. We discovered that if patients were not over-medicated, they could go home the same day.
The first outpatient center cases in the United States began in medical outpatient buildings on the medical campus. Surgeons could actually see the hospital from the outpatient operating rooms, which was a kind of security blanket. If anything did go wrong, the hospital was only minutes away.
At the same time, minimally invasive techniques began coming online. New retractors and tubular systems enabled us to make the same surgical repairs as before but with much smaller incisions. These innovations allowed for reduced blood loss and faster recovery times. Best of all, a drumbeat of patient studies showed that surgery in an outpatient setting was just as safe as a hospital setting. Ambulatory centers also were less expensive and had lower infection rates. Complication rates were equal to or better than those in hospitals.
Can everyone have outpatient spine surgery?
Unfortunately, not everyone is a candidate for outpatient spine surgery.
Patients who qualify for same-day surgery are generally individuals who are motivated to comply with discharge instructions and to perform prescribed exercises. They are also generally healthy. Patients with serious risk factors or health conditions must undergo surgery in a hospital setting. Risk factors include high body mass index (BMI), multiple co-morbidities (such as heart disease and type 2 diabetes), malignant hyperthermia, and sleep apnea. At Mayfield, both the surgeon and the anesthesiologist must approve individual patients for outpatient surgery.
To determine whether patients are appropriate candidates for outpatient surgery, we assess their physical status based on a classification system developed by the American Society of Anesthesiologists (ASA). An individual classified as ASA 1 has no major health problems outside of the injury or disease that needs to be addressed. Patients classified as ASA 2 have moderate problems, such as mild diabetes. Those classified as ASA 3 have more serious conditions, such as severe diabetes, heart disease, or respiratory disease.
At the Mayfield Spine Surgery Center, we started our outpatient procedures conservatively, with the majority of cases involving straightforward lumbar micro-discectomies and decompressions and single-level cervical fusions (ACDF). In 2014, we began to focus on outpatient lumbar fusions. Today, we perform 100 outpatient lumbar fusions a year and more than 300 ACDFs. In 2018 we also performed more complex cases than ever, including 45 ACDFs involving three or four levels.
Not included in the statistics are psychological changes that I believe have been underestimated. When you admit patients to the hospital for what is supposed to be outpatient surgery, patients know that they still have the option of remaining overnight. Later in the day, they may say they’re in too much pain to go home, and it becomes a self-fulfilling prophesy. If patients have surgery at an outpatient center and are told that they are going home the same day, they know they’ll be well enough to go home.
The field of neurosurgery has evolved to allow Mayfield to provide outpatient spine surgery to thousands of patients. As one of the nation’s leading outpatient spine surgery centers, we are proud of what we have accomplished.
William Tobler, MD, is a neurosurgeon with Mayfield Brain & Spine. He is a consultant with Depuy Synthes, Medtronic, and Zimmer Biomet, and he has ownership in the Mayfield Spine Surgery Center.