Minimally invasive spine surgery has become more pervasive over the past five years with enhanced techniques and technology to achieve better outcomes and lower the cost of care. Surgeons across the country are performing these less invasive techniques, and the surgeons at Midwest Orthopaedics at Rush's Minimally Invasive Spine Institute have a hand in promoting minimally invasive spine surgery education, technology and advancement.
"We've now reached an inflection point. Almost any spinal procedure from a slipped disc to scoliosis can now be done minimally invasively," says Kern Singh, MD, co-director of the Minimally Invasive Spine Institute. "That means using smaller incisions and largely sparing the back muscles."
Less invasive procedures have several tangible benefits: less postoperative pain, reduced infection risk, less blood loss, shorter hospital stay, quicker recovery time and the potential to lower the cost of hospitalization and overall care.
Leading in clinical research
Dr. Singh, along with his colleagues at MISI, heads several research projects examining less invasive surgery. Their efforts could make a huge difference in the field, as payers are demanding high-level studies to prove new procedures and technology is the best treatment. Surgeons at MISI were responsible for 40 presentations based on their research at the recent Society for Minimally Invasive Spine Surgery Global Forum — nearly half of all presentations.
"I'm fortunate to have a strong research team around me," says Dr. Singh. "We've taken my 3000+ patients and created a registry so we can collect data. Joint replacement surgeons have been doing this for a long time. Now, as a spine surgeon, I'm able to collect and analyze larger patient populations systematically as opposed to a study of 18 patients or six patients."
The electronic data gathering capabilities allow the MISI team to control for gender, age and race among other key variables and objectively examine how minimally invasive procedures are impacting different patient populations.
"There is a lot of positive and negative press about minimally invasive spine surgery, but there isn't much science behind it," says Dr. Singh. "I took standard procedures — minimally invasive laminectomies, discectomies and fusions — and then tried to understand them scientifically."
In one series of papers, Dr. Singh and his team looked at intraoperative medications and hospitalization for normal open surgery and compared results with minimally invasive procedures. They found the patients who underwent minimally invasive surgery consumed significantly less narcotics. Patients who consume fewer narcotics are able to mobilize quicker and use fewer hospital resources during recovery. It also shows minimally invasive patients experience less postoperative pain in general.
"This is important because people report pain differently, but if you are consuming more morphine, the pain is more significant," says Dr. Singh. "We are under scrutiny from insurers and payers to start looking at the data and showing what we're able to do."
The researchers can now also break down their patients by payer type to see whether there is a difference between Medicare, workers compensation and privately insured patients.
"There's a myth of workers compensation patients taking more medications and staying at the hospital longer, and in the minimally invasive population, they actually didn't," says Dr. Singh. "Then we took it even further and examined whether there was a difference in outcomes based on age. We fund that as you get older, you require less narcotics and that's important because there are a lot of age-related sequela of taking morphine."
Analyzing cost data
Another step further examined whether body mass index made a difference and found morphine didn't change by weight. Typically, it's assumed larger patients will need larger pain medication dosages, but Dr. Singh and his team found that wasn't the case.
"If it's the same procedure, same size tube and duration of surgery, then why should pain change based on all those factors of body mass?" he says. "We replicated this study on several different models. There isn't much data out there like this in spine, but our registry allows us to conduct these types of studies."
Beyond clinical effectiveness, cost analysis is becoming increasingly important as the healthcare system demands the least expensive option while still providing quality care. The registry also allows MISI researchers to conduct a true cost analysis to show the cost of surgery and postoperative care.
"We found out minimally invasive patients were cost-savings despite the higher cost of implants and newer technology," says Dr. Singh. "In the end, the hospital was saving significant amounts of money. We drilled down even further in the data and found opportunities to cut waste, lowering the cost of care even more."
Dr. Singh and his team examined minimally invasive cervical fusion and transforaminal lumbar interbody fusion. The surgeons had been ordering routine postoperative blood labs, but realized since these patients weren't losing much blood during their procedures, the labs were largely unnecessary. They mined patient data for 2,000 to 3,000 patients and found only one or two ever required any electrolyte replacements and no one required a postoperative transfusion.
"Now we have adopted the policy not to check blood levels after single level surgical fusion or TLIF," says Dr. Singh. "Now not even anesthesia requires us to hold blood for these surgeries. That's a huge savings. We are going systematically through this data and hopefully objectifying the benefits of minimally invasive surgery."
Unbiased data can be extremely beneficial during payer coverage and reimbursement negotiations as well.
"When we are up against insurers, we can show cost savings to validate what we do," says Dr. Singh. "We can also justify some of the implant costs that have gone up and show a global cost savings as opposed to just looking at a new gadget and saying we can't afford it."
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