Session: Developing a complex spine and total joint service line program in the ASC

Editor's Note

High-volume joints and spine procedures in ambulatory surgery centers (ASCs) require more than a “healthy” patient—success hinges on rigorous screening, block-and-flow efficiency, tech-enabled standardization, and a culture where anyone can say “stop,” this session’s speakers said. Comprising Robert Bray, MD, FAANS, CEO and founding director of DISC Sports & Spine Center; James Chen, MD, orthopedic surgeon; and Chip Snyders, MD, anesthesiologist and medical director, the panel emphasized the safest and most scalable total joints and spine programs in ASCs rely on these common pillars:

• conservative patient selection
• evidence-aligned protocols
• tech-assisted personalization
• tightly coordinated, block-first workflow among surgeons, anesthesia, nursing, and administrators.

“Nothing is absolute,” Dr Snyders said of eligibility criteria. While most ASCs apply a soft cutoff at ASA ≤ 3 and BMI < 40–45, he emphasized nuance: where the weight is carried (airway vs hips), whether sleep apnea is managed with CPAP, the trend rather than the number for labs (eg, sodium chronically low vs newly 129), and functional status over age. Patients on dialysis, with decompensated CHF or severe pulmonary hypertension, or with unstable cardiac disease remain poor fits for ASC joints or spine. “It’s less a checkbox and more a three-legged stool,” he said, grouping evidence-based guidelines, surgeon/anesthesiologist experience, and interdisciplinary consensus.

Snyders laid out an upstream screen that starts in the office: nurse review, flags via a centralized business office, escalation to a medical board, and—critically—permission for anyone on the care team to halt a case for safety review. He advocated for empowering anesthesia to waive low-yield tests on well-conditioned patients, and for future use of wearables and artificial intelligence to “replace the 5-minute PCP visit” with dynamic cardiopulmonary data.

Once a case is greenlit, center design and block choreography drive speed and safety. The speakers described running two ORs with overlapping tasks: spinal or peripheral blocks and PONV prophylaxis in preop while the room turns; trays opened only when the block is complete; and short-acting agents (no long-acting opioids, no intrathecal morphine) to facilitate same-day ambulation. “You want the surgeon never sitting down,” Dr Chen said, citing a 12-cases-by-12pm model enabled by timestamping every microstep (in room, incision, trials, closure) and eliminating bottlenecks.

Technology multiplies consistency. Dr Chen uses robotic alignment for knees and anterior hips, not for marketing, but to “reduce recuts and time variability,” which preserves block duration and throughput. He also relies on perioperative nutrition protocols—protein loading, vitamin D, hydration, and anti-inflammatory diets—to reduce nausea, weakness, and readmissions. For blood management, both surgeons use tranexamic acid routinely and set hemoglobin flags. Cell salvage is available for anterior hips; vascular backup is arranged for complex spines.

Space, they warned, is often underestimated. “A surgeon walks in and says, ‘I can do it here,’ until you roll in the trays,” Dr Snyders said. Rooms of 650–900 sq. ft. are workable, but sterile processing layout, workflow, and minimizing vendor trays matter more than sheer square footage. Single-vendor implants help; otherwise, preop templating and tray reduction are essential.

The speakers also addressed culture and staffing. Consistent anesthesia teams—skilled in regional blocks and rapid turnover—outperform rotating hospital-based groups. Cross-training circulators and PACU nurses in joint and spine expectations enhances early mobility and discharge readiness. And while the speakers said they avoid routine pain catheters, they reserve them for high-opioid-tolerant patients or complex pain phenotypes.

Finally, they urged ASCs to establish clear “no-go” social criteria: no caregiver at home, no stair-free access, uncontrolled diabetes (A1c ≥8%), or unmanaged OSA should all trigger postponement—not cancellation—until optimized. “Everyone is a candidate,” Dr Chen said. “The question is not, ‘Can you do it?’ but rather, ‘Should you do it now?’”