Ty Thaiyananthan, MD, founder and head neurosurgeon of BASIC Spine in Orange, Calif., discusses the most important elements driving the trend toward minimally invasive outpatient spine surgery.Q: There are many types of procedures described as "minimally invasive" spine surgery. How do you define "minimally invasive"?
Dr. Ty Thaiyananthan: When someone says "minimally invasive," people usually think "small incision," "laser" or "endoscopic surgery." Minimally invasive really means a tissue-sparing procedure that can be done without disrupting the global anatomy. It's usually performed through a smaller incision and there is technology that helps with those procedures, such as an endoscope.
I think minimally invasive surgery is incumbent on the development of technology, hardware and visualization that's been developed over the last few years; that goes hand-in-hand with giving the surgeon the ability to perform these procedures in the outpatient setting.
Q: What are the benefits of outpatient spine surgery versus traditional inpatient procedures?
GT: When surgery is done in the hospital outpatient setting, like our surgery is, you can be discharged within a few hours. A lot of these procedures are trending toward the ambulatory surgery center, and it's interesting to watch in today's healthcare environment that is concerned with cost containment. The same results can be achieved in the ASC for the patient with a lower cost, and you don't have to sacrifice quality. ASCs have been much nicer and better equipped even than some hospitals.
Q: We have seen a slow migration of simple spine surgeries performed at ASCs and now some surgeons are doing increasingly complex procedures there. Do you think ASCs will become a bigger player in the spine space going forward?
GT: There is, overall, a general philosophy centered on patient care and satisfaction at surgery centers — they cater to a very particular patient population. There is no question about it; I think the trend is going to be for more spine procedures to be performed in the ASC. The technology is there and the clinical evidence supports these procedures.
Another point to consider now is that more physicians are partnering with hospitals for joint venture surgery centers. I think, even on a global healthcare level, hospitals and insurance companies can benefit from having procedures performed there.
Q: Why are we able to bring more cases to the outpatient setting than ever before?
GT: Over the past three or four years, the development of technology has allowed us to take patients who would traditionally be in the hospital for three or four days postoperatively to the outpatient setting on a routine basis. We can perform microdisc and even cervical and lumbar fusions as outpatient procedures. Pain relief can be done in the outpatient setting, and that has advanced tremendously over the past decade.
In my case, we have also seen advancements in anesthesia techniques that allow patients to recover faster from their anesthesia. The procedure is done through smaller incisions, which means there is less blood loss for patients.
Q: When the field first emerged, several surgeons were skeptical of outpatient minimally invasive procedures and questioned their safety. With the evolution of this new technology, is safety still a concern?
GT: There is well-published data showing it's actually safer to do some of the minimally invasive techniques in the outpatient setting as opposed to the traditional open procedure. If you do an open lumbar fusion in the hospital setting, you usually see 550ccs of blood loss and an extended hospital stay. It takes patients longer before they can get up and walk around.
With the new minimally invasive techniques, you can perform an outpatient lumbar fusion and only lose around 10ccs of blood. The recovery time is shorter for minimally invasive procedures and there are more positive outcomes. Infection rates are lower for outpatient procedures, which mean better results. The only difference is there is a new set of technical skills required for surgeons who perform outpatient minimally invasive surgeries, and that requires some extra training.
Q: It's often difficult for established spine surgeons to take time away from their practice in order to learn new techniques. Will that be a barrier for minimally invasive procedures in the future or will outpatient spine surgery become more pervasive?
GT: These techniques are becoming more ingrained to basic training at teaching facilities. Surgeons are recognizing the importance of these techniques because they are better than old procedures and they are teaching it to surgeons being trained right now. Once you are out of the training environment, it really is dependent on the physician to stay updated. It's very important to adopt new techniques and processes.
Q: What forces will drive the trend for more established spine surgeons to seek training on minimally invasive techniques?
GT: As with anything, it will be market forces that drive this transition. Patients are becoming increasingly savvier and they have access to the web, which is a great source of information on techniques and different types of procedures. Patients come in well informed about their potential options and increasing numbers are asking for minimally invasive techniques. They are also asking if the surgery can be done outside of the hospital in an ASC.
I think as the general public becomes more informed about the techniques available there, it will encourage a lot of physicians to acquire the skill set to learn minimally invasive techniques.
Dr. G. "Ty" Thaiyananthan is founder of BASIC Spine. BASIC specializes in complex and minimally invasive spine surgery and is at the forefront of pioneering new surgical techniques using stem cells and minimally invasive surgery to treat chronic neck and back pain.
Dr. Ty earned his medical degree from UCSF, did a general surgery internship and neurosurgery residency at Yale and completed a surgery fellowship at Cedars-Sinai Medical Center.
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