Outpatient Spine Surgery Considerations

In the past years and decades, there are less and less spine surgeries in hospital operating theatres (aka admissions) because patients and doctors are opting for their spine surgeries to be done in outpatient settings instead.

This means that it’s day surgeries, and patients typically goes home the same day as the spine surgery and do not stay overnight. They may stay in the recovery room or ward for a couple of hours just to make sure everything is in order and that they’re healing alright.

The reason for this shift includes:

  • Most patients prefer to go home as they prefer the comfort of their own home. The ones that prefer or have to stay over is typically due to severity and complexity of surgery, risk of falls or lack of caregiver at home
  • Costs. It is cheaper financially for the same procedure to be done at outpatient day surgery and no hospital stay versus staying overnight in a hospital.
  • Clinical and surgical techniques have been improving over time and with experience, and safety concerns as less than before.

Because of these, health experts are predicting that 1 in 2 spine surgeries will be done at outpatient day surgery within the next 5 years.

Other benefits of outpatient spine surgery

Other than patients preferring the comfort of their own home as well as lowered costs financially, there is one other very important benefit of outpatient day surgery and not staying overnight in hospital:

  • lowered risk of getting infected or infections such as MRSA or community acquired pneumonia.
  • happier at home = quicker recovery

Who are ideal for outpatient spine surgery?

Not everyone is this ideal candidate, and each additional risk factor must be weighed before offering outpatient spine surgery.

There are criterias to who will be more suited for outpatient spine surgery are

  • Has no other medical conditions or complexities
  • Is of normal weight (body mass index, or BMI, less than 35)
  • Has sufficient care, family or social support at home
  • Has a realistic expectation of some pain and discomfort despite reasonable pain-relief strategies

Lumbar discectomy outpatient spinal surgery

The first spine surgery that was commonly done as outpatient day surgery is lumbar discectomy. It’s a procedure to remove the herniated portion of lumbar disc which presses against the nerve nearby. It has a high surgical success rate, and relieves sciatica (pain that radiates down the thigh and leg).

There are two common options in an outpatient lumbar discectomy

  • microdiscectomy
  • endoscopic (or percutaneous) discectomy

Microdiscectomy

The surgeon minimizes the extent of the operation (as well as potential tissue damage) by using modern microdiscectomy technique. They use a standard incision of 1 to 1.5 inches and focusing the tissue dissection on spreading the muscles and ligaments rather than cutting them.

It’s a targeted approach, and using targeting techniques together with fluoroscope to guide them will help them to minimize the incision necessary to gain a direct view of the surgical location. Magnification allows improved visualization of the nerve sac and the disc herniation. Bayoneted instruments allow precision manipulation of tissues without obstructing the direct view.

The beauty of this minimal approach dissection of the muscles and other soft tissues, this means that

  • there is less local damage, which means
  • less pain and quicker recovery

By removing the portion of the disc that is irritating the nerve, usually the pre-operative radiculopathy pain has diminished or resolved, and many patients can experience immediate improvement in their leg pain when they wake up from the surgery.

Then they will be sent to the recovery room for a couple of hours, go home, ideally with less pain (and more hope) than they had before the operation.

Percutaneous and endoscopic discectomy

This procedure is done with some local anesthetic and mild sedation.

The surgeon inserts a thin tube (or a series of tubes) into the lower back to provide a corridor of sorts to allow access the herniated disc with minimal tissue damage. The incision of each tube is only a few milimeters long, and it’s because they’re so small, there is very little incisional pain.

The main challenge is secondary nerve irritation when the surgeon works through this tube channel during the procedure.

Within the disc, the surgeon will place a guide wire near the neuroforamen. Sequential cannulas (thin tubes) are placed over the central guide wire, gradually widening the tube, in order to push apart the surrounding soft tissues to provide an operative corridor.

Typically when the instruments are removed, the pain is usually tolerable. If there was presence of bone spur or disc material that caused the pain, and if they were removed, there should be reduced pain from before surgery.

Outpatient lumbar laminectomy or laminotomy

For patients with lumbar spinal stenosis, compression in the spinal nerve roots means discomfort and pain.

What happens is that if the symptomatic stenosis area localizes to a few spots, the patient and surgeon can consider modern minimally invasive spinal surgery techniques ie focused decompression of the specific areas of stenosis.

Similar to the process for lumbar discectomy, fluoroscopic guidance can be used to localize the area of stenosis. With the use of

  • small retractors
  • tubular retractors
  • magnification

the surgeon can precisely remove the bone spurs and hypertrophic, or enlarged, ligaments causing the stenosis with minimal disruption of other spine structures.

While the longer-term effects of minimizing the soft tissue dissection may not be completely understood (yet), researchers and clinicians are hoping the minimal soft tissue disruption will also reduce the chances of developing laminectomy-related spinal instability patterns.

Outpatient lumbar decompression techniques reduce the surgical exposure, while achieving the removal of the spinal stenosis-causing structures.

Lumbar interspinous/intralaminar spacers: A limited option

Some surgeons will offer lumbar interspinous/intralaminar spacer devices to indirectly decompress to relieve foraminal and central canal stenosis or to augment a decompression procedure for stability.

Again, we opt to use similar local targeting and dissection techniques as lumbar discectomy, with the overall goal to decompress as well as to minimize trauma to the tissues (it is less beneficial to fix one problem yet create another problem, if we can help it).

To have the procedure as an outpatient, the surgery should be limited to one or two levels of the spine.

Outpatient posterior cervical foraminotomy/discectomy

Similar to outpatient lumbar discectomy and laminotomy, surgical approaches to a laterally located (to the side) cervical disc herniation or foraminal narrowing utilizes the same technique.

  • Fluoroscopic to guide and minimize incision
  • Tissue-splitting techniques reduce the impact to the muscles and ligaments of the spine
  • Magnification techniques and specialized tools can allow for a precise removal of the offending bone, tissue, or disc

There are some important differences that should be considered for the cervical versus the lumbar discectomy procedure.

Cervical discectomy considerations

  • In the cervical spine, the disc herniation should be located to the side (lateral), or near the foramen (the gap in vertebrae in the back and to the side of the spine). With this location, there is no need for any significant retraction on the spinal cord.
  • If the disc is more centrally located, meaning it has herniated toward the back of the spine and is impinging on the spinal cord, the risk associated with moving the cord away from the disc is high. Most surgeons would consider another surgical approach that allows greater visualization, rather than risk causing spinal cord injury.

Lumbar discectomy considerations

The spinal cord starts at the base of the brain, and travels downwards to the sacrum (the bone of the bum/pelvis) and it branches out at ever vertebral level. As it branches out the branched out nerve exits the spinal canal, so it does not run through the lumbar spine.

This nerve branching allows the nerves to be retracted in the lumbar spine without concern for any spinal cord damage. That’s why for most types of disc herniations in the lumbar spine, retraction of the nerve sac is much more acceptable and tolerated in lumbar procedures.

Posterior cervical procedures may have more incision pain following surgery than occurs in the lower back. The reason for this is that the muscles in the neck may be more sensitive to dissection, and patients may find that they may need more muscle relaxants and painkillers during the recovery period.

That being said, outpatient cervical foraminotomy/discectomy is tolerated well by most patients, and there is a high satisfaction with the procedure.

Outpatient anterior cervical discectomy and fusion (ACDF)

For the properly selected patient, one- or two-level ACDF is a safe and reasonable option to address cervical disc pathology.

Some time ago, there was significant concern about potential post-operative complications associated with this technique. Since there, there has been more studies which have documented the efficacy and safety of ACDF in the outpatient setting.

Though the ACDF technique has multiple steps, there is minimal dissection of the tissues.

  • The incision is typically 1 to 2 inches long
  • After the incision to the front of the neck, the rest of the dissection is performed bluntly, with no more cutting
  • The muscles and tissues are gently pushed away from the front of the spine bone
  • There is usually minimal blood loss, and the targeted discs are readily identified and visualized

Because the dissection is performed in a tissue-splitting instead of tissue-cutting fashion, the postoperative neck pain tends to be tolerable.

With resolution of the pre-operative arm radiculopathy symptoms in the recovery area, patients may experience less pain than immediately before the operation. (Radiculopathy is pain caused by irritation of a spinal nerve root.)

So take note of this: as long as

  1. patient can tolerate the pain AND
  2. there is no concern about breathing issues or with difficulty swallowing (dysphagia)

most patients can go home from the recovery area within a few hours of the surgery. Within the past few years, cervical disc replacement procedures have also been performed on an outpatient basis. Using the same exposure techniques, there is no difference in terms of immediate postoperative pain from the ACDF surgery.

Outpatient lumbar fusion

Modern localization techniques and muscle-splitting dissections has allowed outpatient postoperative incisional pain to be low enough to be tolerated with an outpatient day surgery.

In the past 15+ years, there is much advances in spine surgery instrumentation and that has beneficially provided a lot of options of

  • spine screws
  • spine cages
  • spine exposure retractors

What happens is that these instruments are created with one thing in mind: to create a lumbar spine fusion construct that can be delivered using small incisions and muscle-splitting dissections.

No matter how, a surgeon needs to be prudent and be careful to offer outpatient spinal fusion only with the correct indications, overall health, body type, and pain tolerance. While the procedure can be done successfully using these minimally invasive techniques, other factors may determine the appropriateness of an outpatient setting for certain patients.

Specific types of fusion that may be done by an appropriately skilled and experienced surgeon include:

Anterior lumbar interbody fusion (ALIF)

Some surgeons are able to do an ALIF on an outpatient basis. This is largely because an ALIF includes an approach from the front, through the abdomen, so there is minimal tissue disruption.

Lateral lumbar interbody fusion (e.g. TLIF or XLIF)

Similar to an ALIF, a fusion approach from the side approach can be done with minimal tissue disruption. The good things is that this allows the procedure to be done on an outpatient basis in a properly selected patient and with an appropriately experienced surgeon.

As far as lumbar fusions are concerned, at this time, only a small percentage of the patient population will be appropriate candidates for an outpatient experience.

Pain management after outpatient spine surgery

Pain management is a definite necessity for patients to go home after an outpatient spine surgery, and successful outpatient surgeries need a multi-approach to manage pain and swelling.

Some of the approaches includes:

  • The surgeon must be deliberate in reducing the size of exposure while still having excellent visualization of the surgical field.
  • Dissection trauma must be minimized as much as possible.
  • The skin area should be locally anesthetized. The deeper muscle and fascial layers should also be infused with anesthetic. Corticosteroid medications can be utilized to decrease longer-term swelling and inflammation.
  • A combination of narcotic medications, muscle relaxers, and anti-inflammation medications can provide better pain control. Anti-inflammatory medications are not used for any type of fusion surgery, however, such as an ACDF or lumbar fusion.
  • Ice and cool therapies can reduce the postoperative pain and swelling.
  • Pain physiotherapy can help with postoperative mobility and pain management.

Depending on the patient’s medical history, not all these different techniques may be utilized.

Opioid tolerance affects pain relief

Patients having spine surgery may have been on opioids (painkillers) at fairly high doses. Depending on patient’s pain tolerance, this can be for a long time before and after surgery.

If this is the case, patients will have developed a certain level of dependence and tolerance for oral opioids. This means that patients may need more painkillers and may have some difficulty weaning off the pain meds.

To address this issue, some surgeons will try to wean patients off the more potent narcotics prior to surgery. If opioid use prior to surgery can be decreased or eliminated it will to give the prescribed post-operative pain medications a chance to provide acute relief. If post-operative pain management is a concern, admission for inpatient observation may be a better choice.

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