Dear SRS members,
It has been a busy three months since we met in Chicago for the 47th Annual Meeting. I would like to take this opportunity to update you on the activities of your Presidential Line (PL), the Board of Directors (BOD) and the committees during this period, as well as inform you of some future plans.
We had the Cabinet Meeting on October 13th at Hilton O’Hare in Chicago, Illinois, USA. On the preceding day, we had two educational sessions for all attendees, one was about new educational opportunities in the light of our new CME accreditation and the other session was about creating a safe surgical environment. The learned lessons from these sessions will assist the corresponding CME Task Force in reaching their recommendations.
At the Cabinet Meeting, all committee chairs discussed their committee charges and presented their plans to reach their committees goals. All was discussed by the PL and the BOD and then approved. The following are some of the highlights of the meeting.
I am pleased that we have made 300 thousand dollars available for research grants for 2013. This is a 20% increase from our previous commitment for research grants, which asserts our commitment to spine deformity research. We may even increase the fund available for research grants if we receive named research gifts.
The Education Committee is already finalizing the Pre-Meeting Course for upcoming 28th Annual Meeting & Course in Lyon, France which will explore global prospective of the management of spine deformity. The committee plans to have fundamental and timely topics for lunch time symposia and Thursday Half-Day Courses. In a survey sent out to all members last August, members requested more debates and panel discussion in our educational programs. Thus the Education Committee is incorporating your wishes in their planning. The Program Committee is exploring different ways to continue with concurrent sessions yet satisfy all attendees by presenting a synopsis of these concurrent sessions during the general session. I would like to remind you all that abstracts are being accepted now online for the 20th IMAST in Vancouver, BC, Canada and the 48th Annual Meeting & Course. The deadline for submission is February 1st, 2013.
The Worldwide Conferences Committee approved six courses for 2013 covering different regions of the world. These courses continue to be an economically sound endeavor, educationally valuable and serve our mission to improve spine deformity care for all patients worldwide.
The Advocacy and Adult Deformity Committees produced two different surgical indication statements for spine fusion in pediatric and adult spine deformity. Both are available on the SRS website under the advocacy dropdown list. You will be able to utilize these statements in dealing with third-party payers.
As you all know, we received our provisional CME accreditation last July and subsequently have planned our first CME course. It will be a cadaver course in October of next year under the chairmanship of Lawrence G. Lenke, MD and Christopher Shaffrey, MD.
The Educational Program for the 20th IMAST is in its final stage of planning. Thanks to Christopher Shaffrey, MD and Justin Smith, MD, you will notice the program will be well balanced between different spine diseases and will fulfill what you have requested in the recent survey. The educational program for IMAST will continue to be very distinctive from that of the Annual Meeting and will emphasize the new and innovative in the spine field.
We have established our own Research, Education and Outreach Fund, “REO Fund” and I encourage you all to contribute to the REO Fund, as I would like to achieve 100% participation of all members. Even with as little as 100 dollars contribution, full participation will show our commitment to our great society. I would appreciate all of you helping me to reach our goal of 100x100 during this year (100% participation for as little as 100 dollars). It is that time of the year to plan giving and I would sincerely appreciate if you remember REO Fund in your end of the year donation plans.
These are but a few of the activities which took place during last few months. All of the committees and task forces are working energetically to fulfill their considerable tasks. I sincerely appreciate the committee chairs and members for their dedication and loyalty to The Scoliosis Research Society. It is an exciting time for SRS; our meetings continue to draw an even larger numbers of registrations, our educational courses are well received around the world, our support for research and the funds given to research grants are larger than ever and we consistently strive to have a sound fiscal plans SRS. I am honored to be the president of this great society and look forward to many great things to come.
I very much appreciate the generosity of one of the main SRS spokespersons, ladies professional golfer, Stacy Lewis, who won the ISPS Handa Heroes Charity Golf Event on Monday November 19th. She was also recently named the 2012 LPGA Player of the Year. The SRS congratulates Stacy on her continuous success. With this victory, Stacy donated a portion of the winners’ share to the REO Fund and personally matched it with an equal amount. Her contribution will be directed to the 2013 research grants fund under the name “Stacy Lewis Research Grant.” Stacy’s story can be found on one of the panels of the homepage of the SRS website. Please join me in thanking Stacy for her generosity to the SRS.
I would like to thank the Presidential Line: President-Elect Steven D. Glassman, MD, Vice President John P. Dormans, MD and Past President B. Stephens Richards, III, MD for their continuous support and wise advice. I would also thank our very capable staff under the leadership of Executive Director, Tressa Goulding, CAE, CMP.
The Presidential Line and staff wish you all a very happy holiday season.
Best wishes to all,
Kamal N Ibrahim, MD, FRCS(C), MA
Paul D. Sponseller, MD
In contrast to the economic situation for the United States and much of Europe, the finances of the Scoliosis Research Society continue to be healthy. Because of stewardship on both the income and the expense sides of the budget, the Society has the means to continue to maintain a healthy research agenda as well as to expand its educational offerings. Attendance at both the International Meeting on Advanced Spine Techniques (IMAST) and the Annual Meeting was better than expected, due to the strength of the educational programs. This allowed us a modest overage beyond expenses. In addition, industry support continues to be nearly steady, at over $1.12 million, despite competitive pressures. The upcoming year brings an extra challenge, as device companies face a new 2.3% revenue tax imposed by the US Federal Government. Industry support for SRS educational programs accounts for 30% of our income and we intend to be flexible enough to weather any changes in the future.
The Robert B. Winter Fund has been established to honor Dr. Winter, SRS Past President and already contains over a quarter-million dollars. Five percent of this amount will be distributed yearly and used to enhance international education. If you have a desire to honor Dr. Winter but have not done so, please contact the SRS office. The “new” Research Education Outreach (REO) Fund contains over $2.5 million which will be used to enhance our research offering.
The research budget is largely made up of the OREF Designated Giving, distributions from our OREF account and next year from the REO Fund. In 2012 we had $222 thousand available for competitive research awards. This year, President Ibrahim has committed to making that amount no less than $300 thousand, in recognition of the many high-quality research projects that the Research Committee receives. In order to maintain and build our endowment as well as improve our research funding in years to come, we urge each and every SRS member to contribute what they can to the SRS through the REO Fund or OREF. It is a privilege to be Treasurer of such a focused and giving organization.
Lawrence G. Haber
Awards & Scholarship Committee Chair
The Awards and Scholarship Committee has been active since the 47th Annual Meeting and Course. Recently the 2013 Travelling Fellows were selected. The applicant pool was impressive with many qualified candidates that would have been excellent representatives of our society. The selection process was difficult, but after much consideration we chose three extremely qualified individuals: Amer Samdani, MD from Philadelphia, PA, Pennsylvania; Firoz Miyanji, MD, FRCSC, from Vancouver, BC, Canada; and Vikas Patel, MD from Denver, Colorado, USA. Together the three will travel to Europe to visit various spine centers in the fall of 2013. They will conclude there journey at the 48th Annual Meeting and Course. We all look forward to hearing about their adventures. Shay Bess, MD from Denver, Colorado another impressive candidate, will serve as alternate.
An exciting development within our organization is the creation of the Robert B. Winter Global Outreach Fellowship. This award is made possible by the generous donations made to the Winter Fund organized in collaboration between the SRS Administrative office and the Twin Cities Spine Center to honor the amazing career of Robert B. Winter, MD. The goal of this scholarship is to positively impact a physician from a developing country to improve care in that region. The award winner will visit a SRS member’s spine center for up to six weeks, as the budget allows, and then be followed by the surgeon from the hosting center to the award winner’s home institution to add to and enhance the educational process. We are hoping to have applications ready for the Spring 2013 awards cycle.
On a related note, the Awards Committee continues its efforts to update all grading forms and applications. This has enabled us to more objectively and fairly assign all of our awards. In addition, we are launching an effort to get better feedback from all our award winners.
An exciting new project for the committee is being developed in partnership with the Website Committee. We are going to develop a photo slide show on the website that depicts the experiences of our past travelling fellows. If you are a past fellow and have photos you are willing to share, please respond to our upcoming email. We hope this will be an entertaining addition to website. Matthew E. Oetgen, MD from Washington DC will be leading this effort.
Chair: Lawrence L. Haber, MD Committee Members: Stephen J. Lewis, MD, MSc, FRCSC; Youssry MK El-Hawary, MD; Suken A. Shah, MD; Charles E. Johnston, MD; Hubert Labelle, MD; Hilali H. Noordeen, FRCS; Saumyajit Basu, MD; Matthew E. Oetgen, MD; David M. Montgomery, MD; Avraam Ploumis, MD, PhD; John M. Wattenbarger, MD; Khaled Kebaish, MD; Hani Mhaidli, MD; Mohammad Mostafa Mossaad, MD.
John R. Dimar, II, MD
The Education Committee, in combination with the CME Committee, has been reviewing the feedback from the 47th Annual Meeting & Course in Chicago, Illinois, USA to identify potential educational needs of the Society’s membership. From these comments, we have done a basic gap analysis and have sent out an educational survey to all committee members to confirm these needs while concurrently working on potential Pre-Meeting Course curriculum for the upcoming 48th Annual Meeting & Course in Lyon, France. Since next year’s meeting is at an international destination, the committee has decided to focus on the worldwide perspective of the treatment of spinal disease and pathology. Due to this focus, we will be asking many of our international members to participate in the educational program. Our goal is to provide an informative, exciting and highly educational program that is CME accredited to all our members and meeting delegates. Ultimately our goal is to ensure that the program will add significant new knowledge and treatment techniques to all meeting delegates’ practices.
Additional educational opportunities at the annual meeting include three Half-Day Courses and six Lunchtime Symposia, an additional two from last year. The Lunchtime Symposiums are a great learning opportunity for the membership to attend while having lunch and offer a more casual educational environment. We encourage all of the members to try to attend these courses. We have received numerous proposals from the membership for these educational opportunities and the committee will be deciding which ones will be presented over the next several weeks. Some of these proposals are very exciting since they are new topics that have not been presented at previous SRS Annual Meetings. Hopefully, these focused educational proposals will offer the membership various new educational experiences. The final list will be presented after the first of the year with completed agendas.
The American Academy of Orthopaedic Surgeons (AAOS) accepted a two-hour symposium proposal entitle “A Decade of Change in the Treatment of Pediatric & Adult Spinal Deformity: What Innovations in Diagnostic, Guidance & Surgical Techniques Have Proven Effective?” which has been cobranded by SRS. Many of the members who presented at this year’s SRS Annual Meeting will be presenting at the symposium and it is a great privilege for the course accepted into such a competitive meeting. The committee encourages any members at the AAOS meeting in March to attend the symposia.
Chair: John R. Dimar, II, MD Committee Members: Mark B. Dekutoski, MD; Suken A. Shah, MD; Frank J. Schwab, MD; Paul D. Sponseller, MD; Terry D. Amaral, MD; Christopher P. Ames, MD; Michael S. Chang, MD; Robert H. Cho, MD; Brian Hsu, MD; Andrew H. Jea, MD; Elias C. Papadopoulos, MD; Scott S. Russo, MD; Adam L. Wollowick, MD; Lukas P. Zebala, MD; Lori A. Karol, MD; Daniel W. Green, MS, MD. FACS; Sigurd H. Berven, MD; John C. France, MD; Kit M. Song, MD, MHA; S. Rajasekaran, MD, FRCS, MCh. PhD; Mark Weidenbaum, MD.
Praveen Mummaneni, MD
E-Text Committee Chair
The SRS E-Text is now available online through the website. This electronic textbook is now free of charge to both SRS members and nonmembers as a "go anywhere, anytime" online resource covering a broad array of spinal deformity topics.
Currently 47 chapters, many with accompanying surgical videos from master surgeons, are available online. More chapters and videos will be added in the upcoming months. The E-Text can be accessed online using any device with an internet connection. We encourage users to log in and review the latest up-to-date information on a variety of spinal deformity topics. In 2013, the E-Text will be made available as a download by your Smartphone or tablet device. Please be sure to let your residents and fellows know about the E-Text becoming available for their use!
The E-Text can be a quick reference for attending physicians and residents. Everyone is encouraged to at least scan the chapters. They are well-written and illustrated.
-Editor John Lubicky
Chair: Praveen Mummaneni, MD Committee Members: James W. Ogilvie, MD; John P. Dormans, MD; Adrian C. Gardner, FRCS; Sumeet Garg, MD; Dmytro Petrenko, MD; Noriaki Kawakami, MD, DMSc; Fernando Emilio Silva, MD; John C. France, MD.
Laurel Blakemore, MD
Fellowship Committee Chair
The Fellowship Committee reviews all Candidate, Associate and Active applications for SRS membership, providing recommendations to the Board of Directors for final approval at the September and February/March Board meetings. The committee also participates in interpretation of membership policies and procedures as outlined in the SRS
We received an outstanding group of applicants for membership this year. We are pleased to announce our new 2013 Fellows.
Dheera Ananthakrishnan, MD
Paloma Bas Hermida, MD
Satoru Demura, MD
Michael J. Faloon, MD, MS
Nicholas D. Fletcher, MD
Katsumi Harimaya, MD
Michael B. Johnson, MD
Han Jo Kim, MD
Jean-Christophe A. Leveque, MD
Addisu Mesfin, MD
Hideki Murakami, MD, PhD
Jambuladinne Naresh-Babu, MD
Chris J. Neal, MD
Edward K. Nomoto, MD
Miguel H. Puigdevall, MD
Kristen E. Radcliff, MD
Paulo José Silva Ramos, MD
Shoji Seki, MD, PhD
Paul Stanton, DO
Luis Eduardo Carelli Teixeira Da Silva, MD, MSC
Eugene Wong, MD, MS
Shu-Hua Yang, MD, PhD
Jim A. Youssef, MD
Associate Fellows (4):
Linda S. Cree, BSN, RN
Abla M. Hamed, PhD
Marjolaine Roy-Beaudry, M.Sc
Isabelle Turgeon, B.Sc.
Special congratulations to our new Active Fellows, who have successfully completed the five-year Candidate process and are now full voting members (32).
Peter D. Angevine, MD, MPH
Mark A. Barry, MD
Patrick P. Bosch, MD
Jacob M. Buchowski, MD, MS
Michelle S. Caird, MD
Mladen Djurasovic, MD
Shawn R. Gilbert, MD
Hubert Lee Gooch, Jr., MD
Jonathan N. Grauer, MD
Enrique Izquierdo, MD
Hak-Sun Kim, MD
Wael Koptan, MD
Anant Kumar, MD
Robert D. Labrom, MD
Frank La Marca, MD
Ming Li, MD
Mark D. Locke, MD
Anis Mekhail, MD
Hooman M. Melamed, MD
Andrew W. Moulton, MD
Ian W. Nelson, MB, BS, MCh Orth, FRCS
Vikas V. Patel, MD
Alpaslan Senkoylu, MD
Jeffrey Scott Shilt, MD
Katsushi Takeshita, MD
Kent Vincent, MD
Michael G. Vitale, MD
Surya Prakash Rao Voleti, MS, DNB
Klane K. White, MD, MSc
Walid K. Yassir, MD
Xuesong Zhang, MD
Yonggang Zhang, MD
New Active Fellows accepted through the Fast Track program (5).
Michael G. Fehlings, MD, PhD, FRCSC, FACS
Luis Eduardo Munhoz da Rocha, MD
S. Rajasekaran, MD, FRCS, MCh, PhD
Regis W. Haid, Jr., MD
Vo Van Thanh, MD, PhD
New Emeritus Fellows (6):
David D. Aronsson, MD
Jean-Pierre C. Farcy, MD
Glen M. Ginsburg, MD
William A. Herndon, MD
Dan E. Mason, MD
Albert E. Sanders, MD
We are pleased that our first issue of Spine Deformity, the official Journal of the SRS, will be mailed to SRS members in January 2013. Please make sure that your current mailing address is in our data base. Your member profile can be updated online under the Members-Only section of the website.
Thank you all for your dedication.
Chair: Laurel C. Blakemore, MD Committee Members: Carlos A. Tello, MD; Hilali H. Noordeen, MD; Douglas C. Burton, MD; Munish C. Gupta, MD.
Behrooz A. Akbarnia, MD
The SRS Archives – A Historical Collection at the University of Kansas Medical Center
Our society is fortunate enough to have established an endowment fund to support the SRS archives at KUMC. We are now able to store, not only the important documents, but also historical articles for future generations. Below is the description of the archives and how the SRS fellowship can use, as well as.
Nancy J. Hulston, MA
Adjunct Associate Professor – History of Medicine
Director of Archives– KUMC
The Archives of the University of Kansas Medical Center serve as a repository for significant historical artifacts, photographs, books and papers charting the development and accomplishments of the SRS and its members. The Archives are organized for members interested in the history of spinal and orthopedic surgery in the United States and for study by qualified researchers.
The SRS Archives include: Annual Meeting Folders from 1965 to present, Presidential Cycles, Board of Directors Meetings, Committee Reports, Members Business Meetings, Annual Meeting Planning, Presidential Address and Harrington Lecturers Notes, Multi-District Pedicle Screw Litigation, Nominating Committee Notes, Committee Files, Alphabetical Subject Files, Related Meetings and Publications, Presidential Addresses, Harrington Guest Lecturer, Guest Speakers, Orthopedic Bone Screw Products Liability Litigation, Membership Correspondence, Morbidity and Mortality Reports and Financial Statements. Additional materials include photographs, audio-visual media and artifacts. These materials will be added to periodically. Books that were deposited with the archival materials have been distinctively identified, catalogued and shelved in the Clendening History of Medicine Library.
Also affiliated with Special Collections related to the history of spinal orthopedics are the papers of former SRS members Paul Randall Harrington, MD, and Walter P. Blount, MD. During the 1960s, Harrington developed the first successful spinal instrumentation system, which, with few modifications, remained the most widely used system for about 25 years. Over the years Harrington became internationally recognized as an authority on scoliosis. A founding member of SRS, he served as its president from 1972-1973.
Dr. Walter P. Blount was a pioneer in the development of the Milwaukee Brace for treatment of scoliosis and the Blount Staple used in treatment of unequal leg length as an alternative to osteotomy. He did extensive work on Erlacher-Blount syndrome, also known as Tibia Vara, and was one of the first surgeons to recognize fractures in children as a possible symptom of abuse. He served as president of the Orthopaedic Clinical Society (OCS) in 1946 and the American Academy of Orthopaedic Surgeons(AAOS), 1955-1956, and as vice president of the Societe Internationale de Chirugie Othopedique et de Traumatologie International Society of Orthopaedic Surgery and Traumatology (SICOT), from 1963 to 1966.
Individuals interested in contributing historical materials appropriate to the archival collections should contact Nancy Hulston, MA, the university archivist at the University of Kansas Medical Center or Katy Kujala-Korpela at the SRS Administrative Office. Access to the archives is open to SRS members and to qualified researchers who have been granted appropriate permission by the SRS Historian. A portion of the SRS Archives has been digitized and posted in a special segment of the organization’s website: www.srs.org/.
Committee Chair: Behrooz A. Akbarnia, MD Committee Members: Nathan H. Lebwohl, MD, Past Chair; Vishal Sarwahi, MD; Azmi Hamzaoglu, MD; Reinhard D. Zeller, MD; Lawrence I. Karlin, MD; Alistair G. Thompson, FRCS; Jason Lowenstein, MD.
B. Stephens Richards, III, MD
Long Range Planning Committee Chair
The future Scoliosis Research Society (SRS) Annual Meeting sites that have previously been selected are Lyon, France (2013); Anchorage, Alaska, USA (2014); and Minneapolis, Minnesota, USA (2015). Minneapolis will be the host of our special 50th Anniversary of the SRS Annual Meeting. The future SRS International Meeting on Advanced Spine Techniques (IMAST) sites include Vancouver, Canada (2013) and Valencia, Spain (2014). For the 2015 IMAST site, Lawrence G. Lenke, MD (last year’s committee chair) and Executive Director Tressa Goulding, CAE, CMP, will be visiting three potential venues (Korea, Malaysia, and Singapore) in December. The decision for the 2015 IMAST site will be made shortly thereafter by the committee.
A Request for Proposal will be circulated to all SRS members, which will allow members to propose an Annual Meeting site or IMAST site. The SRS staff will review the proposals, maintain a spreadsheet of the proposals and perform preliminary research to determine whether adequate facilities are available. The Long Range Planning (LRP) Committee will discuss these proposals with the IMAST committee and other appropriate committees, and select two to three locations for further investigation, including site inspections. Following site inspections by Ms. Goulding and the LRP Committee Chair, the LRP Committee will discuss and make a recommendation to the Board of Directors. For 2016, the Annual Meeting will be outside of North America and IMAST will be in North America. The committee is currently assessing possibilities for both meetings, and will visit potential venues in 2013.
Factors that are important in the selection process include geographic balance, financial issues, alignment with the SRS strategic plan and educational needs, local support, and adequate facilities.
Committee Chair: B. Stephens Richards, III, MD Committee Members: Lawrence G. Lenke, MD; Youssry MK El-Hawary, MD; Kamal N. Ibrahim, MD, FRCSC; Ahmet Alanay, MD; Christopher I. Shaffrey, MD.
Michael C. Ain, MD
The Non-Operative Management Committee has been very active during the start of the 2013 committee year. The committee members have been working intently to update the SRS Bracing Manual which is available on the SRS website for open use. Most recently, the committee has turned its focus to specifically updating the section on European Bracing. Theodorous B. Grivas, MD, PhD has worked hard to review and provide to the committee several substantial articles to enhance the manuals European section in the annotated bibliography. The Non-Operative Management Committee will be using those articles to develop an effective and balanced chapter on European Bracing. With only a few sections left unfinished, the committee is looking forward to presenting the SRS membership a fully completed bracing manual to consult and use in their practice sometime in the near future.
The Non-Operative Management Committee is also excited to be working on a submission for a Half-Day Course for the 48th Annual Meeting & Course in Lyon, France. While still being developed, the committee will be offering a variety of talks and panels on non-operative procedures affecting scoliosis patients from cradle to grave. The course will be representative of non-operative procedures from around the world with special attention given to developments from our host continent.
Committee Chair: Michael C. Ain, MD Committee Members: Nigel J. Price, MD; Timothy S. Oswald, MD; Patrick T. Knott, PhD, PA-C; Michael T. Hresko, MD; Carlos A. Tello, MD; Luke Stikeleather, CO; Vishwas R. Talwalkar, MD; Joseph M. Verska, MD; Daniele A. Fabris-Monterumici, MD.
R. Dale Blasier, MD
Coding Committee Chair
Many surgeons are performing procedures on the growing spine for Early Onset Scoliosis across the country, which includes VEPTR and growing rod procedures. These procedures, although mature and well-established, do not have their own CPT descriptors. As a result, surgeons have had to choose from existing codes which do not well-describe what is actually done during these procedures.
Because there are no codes which specifically describe these procedures, there are several problems: 1) There are not any standardized description or vignette which applies to these procedures 2) There is not a way to track the number of these procedures done across the country because there is no way to separate growing procedures from standard procedures as they use the same codes 3) It is not possible to track billing and reimbursement for procedures performed on children with early onset scoliosis.
As a result of these problems, the Scoliosis Research Society Coding Committee was tasked with determining whether new codes should be developed which specifically address non-fusion procedures performed on the growing spine. The goals for establishing new codes would be enabling tracking of these procedures, ensuring reimbursement and minimizing denials and to establish correct coding which accurately describes each procedure.
The issue was discussed by the Board of Directors during the 47th Annual Meeting in Chicago, Illinois, USA. It was determined that it would be appropriate to survey the SRS membership to determine satisfaction with the existing codes, determine which CPT codes are being used and assess the level of interest for the development of new codes.
The survey was created and circulated by email to North American members of the SRS in November of 2012. The survey asked if the member performed VEPTR or growing rod procedures and whether they used CPT codes to describe them. Members were asked if they felt they were fairly reimbursed for the procedures. The survey also sought to determine if the member felt there was a need to develop new codes to describe these procedures. Each member was also asked to describe which CPT codes would be used to describe procedures performed during the course of treatment including: 1) insertion, 2) revision, 3) lengthening and 4) removal. The questions were asked for both growing rod and VEPTR procedures.
There was a low rate of response to the survey. Forty three of 61 respondents (71%) used CPT codes to report VEPTR or growing rod procedures. Forty of 59 respondents (68%) favored changing the coding structure for these procedures.
Responses regarding VEPTR procedures:
Thirty two of 63 respondents (51%) performed VEPTR procedures. Only 26% (11 of 42) felt they were fairly reimbursed for their work.
The majority of respondents reported VEPTR insertion procedures using codes for insertion of segmental instrumentation. A smattering of respondents reported insertion of non-segmental instrumentation, unlisted procedures, or did not know what to use. For revision or reinsertion, the majority reported the use of 22849 (reinsertion of hardware) and 22850 (Removal of posterior non-segmental instrumentation). A smattering used an unlisted code or were not sure. For lengthening, almost all used the reinsertion code – 22849. For removal, most reported 22850 (removal of posterior non-segmental instrumentation) or 22852 (removal of posterior segmental instrumentation)
Responses regarding growing rod procedures:
Thirty six of 51 respondents (71%) performed VEPTR procedures. Only 40% (15 of 38) felt they were fairly reimbursed for their work.
The majority of respondents reported growing rod insertion procedures using codes for insertion of segmental instrumentation. A smattering of respondents reported insertion of non-segmental instrumentation, unlisted procedures, or did not know what to use. For revision or reinsertion, the majority reported the use of 22849 (reinsertion of hardware) sometimes with 22850 (removal of posterior non-segmental instrumentation). A smattering used an unlisted code or were not sure. For lengthening, almost all used the reinsertion code, 22849. For removal, most reported 22850 (removal of posterior non-segmental instrumentation) or 22852 (removal of posterior segmental instrumentation).
Problems with utilization of existing codes.
Correct Coding: There are several problems with using existing spinal instrumentation codes: 1) Spinal codes are being used in VEPTR cases in which the hardware does not make contact with the spine. 2) Hardware insertion codes are “add-on” codes and cannot be used in isolation without a “base” code such as arthrodesis. 3) The reinsertion code is being reported, even when no hardware is removed or inserted. 4) There is no agreement among users as to which codes to use. In short, the use of existing codes violates principles of correct coding.
Surgeon satisfaction: Sixty-eight percent of respondents favored changing the coding structure for these procedures. With regard to VEPTR procedures, only 26% of respondents felt they were fairly reimbursed for their work. With regard to growing rod procedures only 40% of respondents felt they were fairly reimbursed for their work.
The Development of new codes
It appears appropriate to proceed with developing a set of codes to describe growing rod and VEPTR procedures for the following reasons:
The current plan is to proceed with the development of relevant new codes for these procedures with the assent of the SRS Board of Directors. Member comments for or against this proposal can be sent to Brian Lueth (Blueth@SRS.org).
Committee Chair: R. Dale Blaiser, MD Committee Members: Jeffrey B. Neustadt, MD; Neel Anand, MD; Christopher J. DeWald, MD; Michael P. Chapman, MD; Mathew D. Hepler, MD; Nigel J. Price, MD.
James W. Roach, MD
Ethics Committee Chair
Orthopaedic surgeons make ethical decisions every day, often without a great deal of deliberation. The vast majority are straight forward, consistent with good patient care and occur because of common sense and appropriate judgment. The actions of individual members of professional societies, such as the Scoliosis Research Society (SRS) reflect on the society and every other member in the society. Thus members are expected to abide by the applicable Standards of Professionalism (SOP) which have been established by the society to help members properly conduct themselves as they treat patients, interact with government, insurance companies and the community. However many of the SOP rules are prescriptive, you should or you should not do.…., thus simply following these rules does not always satisfy all moral obligations. Some patient care issues or situations are so unique and complex that determining the best ethical decision requires more than just rules. These situations require an assessment and perhaps assigning a weight or value for the pros and cons of each possible outcome relative to the best interest of the patient. The following describes a hypothetical issue and the ethical reasoning that can be used to assist moral decision-making.
“Is it unethical to perform Ponte osteotomies in every scoliosis surgery?”
After inserting an all pedicle screw construct for a thirteen year-old female with a supple fifty degree right thoracic curve, the staff surgeon directs the fellow to perform Ponte osteotomies over the apical five levels. The fellow is surprised that Ponte osteotomies would be needed as the curve is very supple with the preoperative bend films demonstrating correction to ten degrees. The staff surgeon replies that he always does Ponte osteotomies as he feels they result in better deformity correction. Should the fellow be concerned that this reasoning presents an ethical dilemma?
The fellow likely posed the question because the use of apical Ponte osteotomies in such a supple curve deviated from his or her past experience. The standard of care in orthopaedic surgery is often fairly broad, allowing substantial variation in treatment technique. To decide if this case or any other poses an ethical problem we need to consider the definition of moral behavior which American Heritage defines as acting in accordance with standards and precepts of goodness or with established codes of behavior. Fortunately, in medicine, moral behavior is less vague as it is described as behavior that is in the best interest of the patient. Behavior that is intended to be the best for the patient is a starting point for moral reasoning in medical ethics.
Four basic principles are commonly used to aid moral reasoning in medical ethics:
1. The principle of non-maleficence – this requires the surgeon to avoid harming the patient. This is usually construed as not providing treatment where the risks outweigh the benefits but it also requires physicians to withhold ineffective treatment.
2. The principle of justice – the treatment rendered must be fair to the patient and or society from the stand point of benefits, risks, and costs.
3. The principle of respect for autonomy – this necessitates that the physician respect the patient as an individual, who, when given adequate information, can provide autonomous choices regarding treatment.
4. The principle of beneficence – when possible the surgeon has a responsibility to help the patient.
These basic principles can be used to evaluate this staff surgeon’s decision to always perform Ponte osteotomies. In this case, adding Ponte osteotomies would not produce any improvement noticed by the patient in functional outcome, curve, or deformity correction. This would fall short of the principle of non-maleficence as the provided treatment would be ineffective. The osteotomies carry some risk of unintended consequences such as bleeding which might lead to hematoma, neurologic deficit or infection. This also involves the principle of non-maleficence as harm could result from an ineffective treatment. The osteotomies add significant extra cost to the procedure and whether the costs are born by the patient or an insurance company is not morally relevant in this deliberation. This illustrates the principle of justice. Respecting the patient’s autonomy would require the surgeon to discuss the need for Ponte osteotomies along with the rest of the surgical procedure. The discussion should indicate how the patient will be helped by this portion of the operation, the possible complications and costs. The principle of beneficence is not involved in this example case.
In this analysis, the routine use of Ponte osteotomies in every scoliosis surgery would violate three of the four basic principles of medical moral behavior and thus is not warranted. Nevertheless a different conclusion would have likely been reached if the case patient had a more severe and stiffer curve. This analysis is not directly about Ponte osteotomies rather it outlines the ethical dilemma of routinely performing a costly and potentially risky operation when it offers no benefit to an individual patient.
Chair: James W. Roach, MD Committee Members: J. Abbott Byrd Jr., MD; M. Wade Shrader, MD; Michael J. Bolesta, MD; Richard E. McCarthy, MD; Brian G. Smith, MD.
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