Outpatient Transforaminal Endoscopic Decompression for Spinal Stenosis Linked to Cost Savings

Peer Reviewed

Outpatient transforaminal endoscopic decompression for lumbar foraminal and lateral recess stenosis performed at ambulatory surgery centers confers an excellent value proposition owing to cost savings associated with lower complication and readmissions rates when compared with microdiscectomy, according to a retrospective review published in the February 22 issue of the International Journal of Spine Surgery.
Surgeon holding a spine model with a lateral x-ray image in the background.Spine Surgeon points to a lumbar spinal nerve root on a model. Photo Source: 123RF.com.“The study provides reassurance to both surgeons and payers that there is a real value proposition with outpatient endoscopic spine surgery,” study author Kai-Uwe Lewandrowski, MD, told SpineUniverse. “This study shows that the complication rate with outpatient endoscopic spine surgery was lower than that for traditional microdiscectomy.”

The retrospective review included data from 1,839 consecutive patients (1,072 female and 767 male) treated with transforaminal endoscopic foraminotomy and microdiscectomy at 2,076 levels by Dr. Lewandrowski at the Center for Advanced Spine Care of Southern Arizona in Tucson between 2006 and 2015. The patients were followed for a mean of 33 months (range, 24 to 85 months).

Surgical Complication Rate Was Less Than 2%

The overall rate of surgical complications in this study was 1.42%. Surgical site problems were uncommon with only 2 patients (0.11%) requiring treatment for infection. The most common post-operative complications were chronic obstructive pulmonary disease exacerbation (0.6%) and reherniation after discectomy for extruded disc fragment (0.5%). Only two cases (0.11%) of durotomy and 2 cases of foot drop (0.11%) were reported.

Transient dorsal root ganglion irritation causing post-operative dysesthetic leg pain was the most common procedure-inherent sequelae, occurring in 229 patients (12.45%). This irritation improved with supportive care in all cases. Failure to cure was found in 80 patients (4.35%).

The rate of acute-care readmissions was 0.87%, with dorsal root ganglion irritation prompting unplanned visits to the emergency room in 9 patients (0.49%), inadequate pain control in 5 cases (0.27%), and infection in 2 patients (0.11%), respectively.

Elderly patients, in particular, may benefit from endoscopic spinal surgery, Dr. Lewandrowski told SpineUniverse. Previous research by Modhia and colleagues found that advanced age is a key risk factor for the relatively high 2-year readmission rates found in Medicare patients undergoing traditional spinal stenosis decompression surgery (12.5% in that study), Dr. Lewandrowski explained.1

Complication Rate Was Surprisingly Low

“I was surprised by the fact that the complication rate was in fact that low,” Dr. Lewandrowski said. “If you consider accepted published complication rate for outpatient microdiscectomy within the 4% to 5% range,2,3 the combined complication rate for transforaminal endoscopic decompression surgery in the current study was one magnitude lower.”

“In skilled hands, nerve root injuries—commonly perceived as a major risk of endoscopic spine surgery—were very uncommon and occurred less frequently than commonly thought. Temporary nerve root irritations that resolve fairly quickly with supportive care such as injections, physical therapy, and activity modification are of greater relevance and patients should be educated about them pre-operatively” Dr. Lewandrowski said.

Findings Justify Coverage of Outpatient Endoscopic Decompressions

“The findings confirm the feasibility of transforaminal endoscopic decompression surgery in the outpatient setting and suggest that complications rates may be lower than previously thought,” study author Kai-Uwe Lewandrowski, MD, told SpineUniverse.

“We sometimes get pushback from payers during the pre-operative authorization process, with some insurance companies calling the procedure experimental,” Lewandrowski said. “Thus, part of the motivation for conducting this trial was to add more supportive evidence to the peer-reviewed literature supportive of these advanced clinical protocols.”

Future Research Is Aimed at Endoscopically Assisted Fusions

“Future research in our program is directed towards looking at the feasibility of broadening the indication for endoscopic surgery,” Dr. Lewandrowski added. International experts in spine surgery are researching use of endoscopically assisted fusion surgeries for the treatment of instability-related symptoms. Dr. Lewandrowski and his colleagues also hope to determine whether these outpatient fusion procedures are linked to optimal clinical outcome and an equally good value proposition in terms of healthcare dollars spent.4

Commentary

Choll W. Kim, MD, PhD
Associate Clinical Professor of Orthopaedic Surgery
University of California San Diego

This study is important for several reasons. First, the study includes a sufficient number of patients and an acceptable rate of follow-up that is necessary to reveal a reasonably accurate prediction of complication rates, especially when these complications are uncommon/rare. Very few studies published in spine surgery include more than 1,000 patients.

Second, the surgeries were performed by a single surgeon at a single center. Although it is usually better to have multiple surgeons from various practice settings/regions included in a study, the technical difficulty and associated learning curve of lumbar endoscopic surgery can be diluted when there are multiple surgeons of varying degrees of experience and skill. This is an important consideration when comparing results with microdiscectomy, which is a well-established procedure taught throughout residency and fellowship training programs. In this respect, this study represents the outcomes that are expected when endoscopic lumbar surgery training occurs in a similar manner.

Finally, lower complication rates combined with improved efficiencies of the ambulatory surgery center address the issue of higher up-front costs associated with endoscopic surgery as compared to traditional open surgery. This has been a significant obstacle to providing this treatment for our patients given recent reimbursement policies that do not differentiate between the different types of procedures. This study shows that advancements in technology that improve patient outcomes and decrease surgical morbidity eventually lead to lower overall costs.

Knowing what is possible, it is imperative that we continue to work on improving the learning curve of this significant technical advancement in spine surgery, while simultaneously working with payers to create a more reasonable reimbursement environment.

Disclosures
Dr. Lewandrowski has no relevant disclosures.

Dr. Kim is a consultant for Globus Medical, elliquence, Spinal Elements, K2M, Allen Medical/Hill-Rom, and ORHub.

Updated on: 03/26/19
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What Are the “Critical Elements” of Spine Surgeries?
Kai-Uwe Lewandrowski, MD
Orthopaedic Spine Surgeon
Center for Advanced Spinal Surgery
Choll W. Kim, MD, PhD
Associate Clinical Professor of Orthopaedic Surgery
University of California San Diego
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