Jeffrey R. Carlson, MD, MBA, CPE, FAAOS
In the old days (a mere 10-15 years ago), when I performed a multi-level spine fusion on a patient, it was considered a really big deal by the insurance company and required an inpatient hospital stay of at least two or three days, maybe more. Now, I perform the same surgeries at an Ambulatory Surgery Center and the patient goes home a few hours after surgery. So, what has changed? In this series of articles, I will discuss how the surgical technique, instrumentation and biologics, better anesthesia, pain management, home nursing care, physician attitudes toward innovation and even hospital care and insurance have all evolved, mandating a huge revolution in the delivery of healthcare and in surgery as well.
The evolution of minimally invasive surgical technique has been a real game changer in the field of spine surgery. As a surgeon, I want to have the smallest incision possible for my patient while at the same time allowing myself enough room in the surgical field within which to do the procedure and to visualize everything I need to see. Special surgical tables are used that enable spine surgeons more easily and comfortably position patients for better access to the vertebrae and disc spaces.
With today’s advanced surgical instrumentation and biologics specifically designed for micro-spinal surgery (some of which I have helped to create), I’m able to fuse the vertebrae with less trauma using only the minimum amount of titanium rods, plates, screws, cages, biologics (man-made bone) or cadaver bone material. The development of specific hardware that can be placed through smaller incisions and provide the same or better outcomes for a patient’s specific disorder has made surgery less painful for patients and improved their recovery.
When I remove the spinal disc (think “jelly doughnut” – a harder outer shell and jelly-like filling that sits between the spinal vertebrae) during a spinal fusion, there is a space left between the bones. This space between the two bones can be used to enhance the bones fusing together. This space can be filled with cadaver bone or a biologic “synthetic bone” to help get the process going. Specially designed intervertebral cages are used to support the space between the bones from the disc removal as the bone graft encourages the fusion.
Anesthesia has also dramatically changed and improved over the past two decades. Older generation anesthesia would require a day or two for the patient to fully awaken. These longer lasting effects of the anesthesia would take longer to dissipate before the patient could be safely discharged home. Modern anesthesia medications are effective, quick to sedate the patient, short-acting and typically have fewer side-effects, such as nausea and vomiting, than the older medications. They do get stored in a patient’s body fat and can take a while to metabolize out of the system; however, modern anesthesia is light years ahead of what it used to be, in terms of patient safety. Often, if pre-medication is administered, it is done by the anesthesia team right before the patient is wheeled into the OR.
Another form of anesthesia that is often used is the nerve block, where the anesthesiologist will numb a specific nerve that affects an entire area of the body. In spine surgery, we use longer-acting local anesthetics at the surgical incisions to decrease the pain related to the surgical manipulation. These long- acting anesthetics will decrease the initial pain of the surgery and decrease the patient’s need for stronger narcotics after surgery.
Spine surgery is a delicate surgery of millimeters and absolute accuracy that requires the patient to be absolutely still during surgery. There is no wiggle room (pun intended) when I am operating near the spinal cord and spinal nerves. As such, it requires that the patient be “asleep” AND paralyzed, so we use general anesthesia. The patient must be intubated and put on a ventilator to assist them with breathing while undergoing surgery which keeps them from moving throughout the surgery.
In the next article, I’ll detail how pain management has changed to allow for outpatient cervical and lumbar fusion surgery.