Outpatient Spine Surgery: Defining the Outcomes, Value, and Barriers to Implementation

Abstract and Introduction

Abstract

Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Introduction

Spine surgery is one of the most impactful targets for reducing costs within the United States health care system.^[32] An estimated $90 billion is spent each year on the diagnosis and management of low-back pain alone.^[28] As summarized by Resnick et al., spinal disorders are an ideal target for cost reduction because of their high prevalence and significant contribution to morbidity- and disability-related costs.^[36] Furthermore, there is significant variability in the treatment paradigms for spinal disorders—representing the entire spectrum of pain medications, acupuncture, massage therapy, steroid injections, surgical decompression and fusion, and beyond. It is the enormous clinical burden of spinal disease paired with treatment heterogeneity that creates an opportunity to empirically define real value and produce savings for the health care system.

One promising but controversial cost reduction strategy involves transitioning surgical procedures to an outpatient setting. More than 54 million outpatient procedures are performed annually in the United States. Among Medicare beneficiaries, rates of outpatient surgery have increased by 40% in the last 10 years. And the number of ambulatory surgery centers has grown by 60% within the same time period.^[21] Although eye surgeries, arthroscopic procedures, peripheral nerve cases, and soft tissue cases represent the majority of ambulatory operations, an increasing proportion of spine surgeries has transitioned to the outpatient setting.^[2,5,7] Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations.

In this focused review, we clarify the different definitions used in studies describing outpatient spine surgery. We also discuss the body of evidence supporting the transition of each of these procedures to an outpatient setting and summarize the proposed cost savings. Finally, we examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Neurosurg Focus. 2018;44(5):e11 © 2018 American Association of Neurological Surgeons