Neurosurgical Training Requires Embracing Ambulatory Surgery Centers

Ambulatory surgery centers (ASCs) have revolutionized resident education in surgical fields and are poised to play an increasingly crucial role in neurosurgery. Traditionally, surgical training occurred in large tertiary hospitals, but ASCs have introduced a transformative paradigm, offering residents a unique learning opportunity.1 The incorporation of ASCs in resident education offers significant advantages because of the emphasis on efficiency and specialization. Designed for streamlined outpatient procedures, ASCs allow residents to participate in a diverse range of surgeries within a condensed timeframe, promoting proficiency in various surgical techniques.2 The management of diverse and complex pathologies in the outpatient setting is driven by the escalating costs of health care procedures. Studies indicate a noteworthy 30% to 40% reduction in the overall cost of spinal procedures in the ambulatory setting compared with in-hospital costs.3,4 This financial efficiency is crucial for ensuring accessible and affordable health care. Residents gain valuable insights into a patient-centered streamlined process and a nuanced understanding of the business and administrative facets inherent to ASC operations—areas typically not covered in traditional hospital settings. Ensuring patient satisfaction and minimizing patient derogation have been paramount goals in the evolving landscape of medical care. ASCs can contribute to this goal by avoiding delays and cancellations, avoiding daily struggles of a traditional hospital setting such as insufficient beds, staffing shortages, and unexpected operating room emergencies. Outpatient centers emerge as an ideal solution to these challenges by providing a dedicated environment for elective neurosurgical procedures. Patients benefit from the assurance that their scheduled procedures will proceed as planned, minimizing stress and uncertainty for both patients and providers. This commitment to timekeeping enhances the patient's experience and underscores the transformative potential of ASCs delivering high-quality, individualized care. Technological advancements in neurosurgery have driven the transition of procedures from traditional hospitals to ASCs. A decade ago, Baird et al5 demonstrated that 84.2% of US spine surgeons were already engaged in ambulatory surgery, with common procedures including single lumbar diskectomy (70.8%), multilevel diskectomy (41.7%), single and multilevel lumbar laminectomy (62.5% and 33.3% respectively), and one-level and two-level anterior cervical diskectomy and fusion (54.2% and 39.6%, respectively). Procedures once deemed complex for an ambulatory setting are now routinely performed with improved patient-reported outcomes and lower costs.6-8 The adoption of minimally invasive procedures, endoscopic decompressions, single-position spine surgeries, and enhanced recovery after surgery protocols have significantly facilitated this shift.8-13 Functional neurosurgery, traditionally exclusive to hospitals, has also witnessed a shift to ambulatory settings. Deep brain stimulation, commonly performed in 2 stages, with the first stage requiring overnight in-house postoperative monitoring and the second stage (subcutaneous chest generator and extensions implantation) often completed as an outpatient procedure.14,15 With careful patient selection, the implantation of intracranial leads may also be performed in the outpatient setting. Neuromodulation surgeries for refractory pain, including spinal cord stimulation devices for postlaminectomy and complex regional pain syndromes and occipital and trigeminal nerve stimulators for chronic pain, are performed safely as minimally invasive outpatient procedures.6,7 ASCs are designed for these common and less complex procedures, offering fast patient turnover and a more predictable timeline than a traditional hospital setting. An emerging trend in neurosurgery is the use of high-end, incision-less technology, such as gamma knife stereotactic radiosurgery and magnetic resonance imaging–guided high-intensity focused ultrasound thalamotomy or pallidotomy.16-19 These procedures offer fast recovery with high safety profiles, broadening access to treat various intracranial pathologies in an outpatient setting. Advancements in the endovascular field now make it feasible and a reality to perform simple endovascular cases on an outpatient basis. The evolution of endovascular therapy has revolutionized the management of cerebrovascular patients, shifting the treatment paradigm from extended hospital stays for open surgical procedures to overnight stays for endovascular interventions. This advancement challenges the boundaries of traditional tertiary care settings and prompts exploration into the incorporation of these procedures into ASCs. Diagnostic cerebral angiograms have exceedingly low (<0.1%) permanent, severe complications and are routinely performed as same-day procedures.20 Meticulous patient selection and surgical expertise hold the potential to further reduce this already low rate. Although part of the neurosurgery residency curriculum will always emphasize inpatient care, resident education must adapt to this new model representing the present and the future. Failure to migrate components of residency training to ASCs will deleteriously affect training because of the paucity of cases that will still be performed in tertiary resident teaching hospitals. Thus, it is our responsibility as clinicians and educators to recognize this transition and consider early adoption of resident education to the ambulatory setting.21 To transition neurosurgical training incorporative of ASCs, several key steps are necessary: (1) streamline resident schedules to eliminate the tension associated with the responsibilities of simultaneous inpatient and outpatient duties, (2) create a culture at ASCs that is conducive to resident education, (3) establish a stable team for continuity of patient care, and (4) develop a structured curriculum covering outpatient procedures, patient-centered care, and the business aspects of managing an ASC.22 The future of ASCs holds immense promise and will push the boundaries of the scope of outpatient neurosurgical procedures. Among the advancements anticipated, the use of minimally invasive procedures and advancements of cutting-edge techniques will revolutionize ASC capabilities. The evolution of ASC will usher in a new era of outpatient care where intricate surgeries once exclusively performed in the traditional hospital setting can now be seamlessly performed in these specialized centers. From minimally invasive multilevel spinal procedures and focused ultrasound-guided stereotactic surgery to endovascular procedures, the possibilities are limitless. We are only scratching the surface of the possibilities that ASCs hold for the future of neurosurgery. Now is the opportune moment to integrate resident education into ASCs to sustain and expand their horizons within neurosurgical subspecialties. In this rapidly evolving health care landscape, where efficiency and superior clinical outcomes are emphasized, the future has arrived, demanding resident education to adapt and align with these advancements.