SRS Newsletter

President’s Message

Greetings to all of our members around the world.

We have just completed an outstanding IMAST meeting in Washington, D.C. Congratulations to Ronald Lehman, Jr., MD and Henry Halm, MD and the IMAST committee for all of their work in making it a success. We had 876 attendees and there were 176 abstracts along with many symposia, debates and as always conversation at the breaks. Next year, IMAST will be in Cape Town, South Africa. It is not too early to start planning your itineraries. The Long Range Planning Committee has recommended and the Board of Directors has approved Amsterdam to be the site for the 2019 IMAST meeting.

The Annual Meeting in Prague will be outstanding. Having done a site visit last year, I will personally say, Prague is the most beautiful city that I have ever been to; you will want to spend some time seeing the sites.  Justin Smith, MD, PhD, and the Program Committee have done herculean work in reviewing  the 1541 submissions. 130 were selected for 4 minute podium presentations (53% are from outside of the US), 107 for e-posters, and 12 for case discussions. Theodore Choma, MD and the Education Committee have put together a great Pre-Meeting Course focused on risk stratification for adult and pediatric spinal deformity. There will also be a great opportunity for Lunchtime Symposia and the Thursday afternoon Half-Day Courses.

Marinus de Kluever, MD, PhD, and the Worldwide Course Committee continue to be quite active. In 2016, courses have been held in China, England (Britspine), Russia, Indonesia (the first SRS formal program ever in Indonesia). Upcoming courses are pending in Japan and Chile in2016 and, for 2017, courses have been approved in Brazil (with SILACO and the Brazilian Spine Society) and India (with ASSICON).

The future of the SRS educational efforts is being evaluated by an education task force led by Kenneth MC Cheung, MD. He and the task force are looking at how SRS should plan educational events going forward. We expect no change in the IMAST and Annual Meeting activities but do see opportunities in our Worldwide Courses and our Hands-On Courses moving forward. More information will follow from Dr. Cheung in the near future.

The Global Outreach Program continues to be very active and the committee has developed a proposed database for surgeries done at GOP sites around the world. This database would be compatible with the SRS Morbidity and Mortality reporting requirements. They have also developed a tiering structure to rate the sites. The goal is a roadmap or pathway for the sites to become self-sustaining over time. The Bulgaria site has essentially achieved this status.

SRS is in good shape financially.  Total assets are up about 3% compared to the prior year. We currently have five Double Diamond industry partners - DePuy Synthes, Globus Medical, K2M, Medtronic and NuVasive. We thank them for their significant level of commitment to our Society. We also thank all of our industry partners for the commitments they are able to make as well.

I personally think that the quality and usefulness of articles in our journal, Spine Deformity, continues to improve. In the latest issue, I really liked the paper by the Adult Deformity Committee. There were several other great articles that will affect my practice as well. The Editor, John Lonstein, MD, and his team have submitted an application for citation in PubMed. We should hear back in the October/ November time frame.

Non-fusion treatment of scoliosis has become a hot topic recently in the United States. There are not any FDA approved devices currently for anterior tethering procedures. Some surgeons are doing physician directed use of existing posterior devices to perform anterior tethering. This is the practice of medicine and is not regulated by the FDA. However, there are some caveats about advertisement and prospective research.

Members of the SRS Pediatric Device Task Force met with the FDA prior to the IMAST meeting. We learned a number of useful items. The only legal way to prospectively study an unapproved or off-label device is through an Investigational Device Exemption (IDE) study. There is a pathway to do physician led IDE’s and the task force will be pursuing the development of a boilerplate format for a physician directed IDE for anterior tethering. This will be made available for members who wish to pursue this strategy.  We also learned more about the details of what is considered an off-label promotion. If a website claims that an off label procedure or device is safe and effective, even if the physician or website has no relationship with the manufacturer of the device, that is considered off label promotion.

The SRS Presidential Line and Board of Directors are in the midst of reviewing efforts for society directed research going forward. In my time on the Presidential Line, I have become convinced of the importance of facilitating research work that is important to our Society. As I said in my IMAST presidential address, I think there are three areas that are timely and critical for us as a Society. This includes predictive modeling for curve progression based upon the initial visit and radiograph, determination of growth remaining so that growth guidance strategies can be optimally applied, and finally patient level risk calculation/prediction for adult spinal deformity surgery.  The point of this discussion is to figure out a way to do appropriate peer reviewed evaluation and support for these types of topics. This will not replace the unsolicited research proposals that the Research Committee currently reviews and recommends for funding, this will be in addition to their valuable work.

Finally, the Nominating Committee led by past president, John Dormans, MD, has proposed a slate of officers for approval by the membership at the Annual Meeting. The slate includes:

  • Vice President – Peter Newton, MD
  • Directors – Sigurd Berven, MD;  Douglas Burton, MD; and Hani Mhaidli, MD, PhD
  • Fellowship Committee – Baron Lonner, MD

Congratulations to those nominated and thank you to the committee members for their significant considered evaluation of all of the qualified candidates.

I look forward to seeing everyone in Prague very soon!

Best wishes and safe travels,

David W. Polly, Jr, MD
SRS President 2015-2016

In Memoriam

Klaus Zielke, MD
1931-2016

It is with great sadness that I have to announce the death of Dr. Klaus Zielke, to the SRS membership, who passed away on May 17, 2016.

Dr. Zielke was born on February 20, 1931. After receiving his german high school degree, he first completed an apprenticeship as a carpenter and then entered medical school in Duesseldorf, Germany. After receiving his degree as a medical doctor, he did parts of  his residency program in pathology, internal medicine, gynacology and also in orthopedic surgery at various hospitals, until he entered a residency program in orthopedic surgery at the University of Tuebingen in southern Germany.

Since no other resident was scientifically interested in the treatment of scoliosis, the programme director forced him into this field. He soon realized that there was no systematic approach to the treatment of scoliosis in Germany at that time, other than in the US with for instance Ferguson, Risser, and Cobb.

After a few cases of Harrington instrumentation, he was not allowed to use the system anymore, since the program director did not consider it a useful procedure.

After a few years as a board certified orthopedic surgeon in Mannheim, where he then used Harrington instrumentation routinely, he opened up the first German scoliosis center at the German-French military hospital, Emile Roux in Tuebingen. He had inspiring visits with Harrington in Houston, TX, USA; Stagnara in Lyon, France, and of course also Dwyer in Melbourne, Australia, who at that time had just invented the first anterior instrumentation system for correction of scoliosis from the anterior approach.

With Dr. Dwyer he discussed the shortcomings of his instrumentation and was encouraged by Dr. Dwyer to improve it. He modified the screw and replaced the Dwyer cable with the Harrington compression rod. With this internationally so-called Zielke instrumentation, he was the first spine surgeon to be able to truly derotate the spine. Other inventions from his side were the growing Zielke-Ascani rod for treatment of early onset scoliosis and of course the Harrington –Outrigger, just to mention a few. He also was the first to correct fixed kyphotic deformities of the spine in ankylosing spondylitis of the spondylarthritic type with multisegmental V-shaped osteotomies, very similar to the later published Ponte osteotomies.

His German Scoliosis Center in Tuebingen got so popular among patients, that in 1978 he had to move it to a much bigger hospital, the well known Werner-Wicker Klinik in Bad Wildungen with more than 100 beds for scoliosis patients. Many spine surgeons from all over the world visited over the years, to attend international courses on Zielke instrumentation and other techniques. I had the luck and honor to have been the last resident hired by Dr. Zielke in April 1989. Due to health issues he had to retire half a year later.  However, even years after that he was still involved in innovations of implant systems and influenced my scientific career significantly.

He truly is the father of modern deformity surgery in Germany. He was an inspiration for every orthopedic surgeon interested in spinal deformity surgery at that time. Like many others, I can not thank him enough for his inspiration and influence on my career.

Our thoughts are with his wife Haifa and his daughters.

Obituary was written by Henry Halm, MD


Klaus Zielke, MD with his wife Haifa.

Pat on the Back

Congratulations to Marinus de Kleuver, MD, PhD, on his appointment as the Head of Department of Orthopedics at Nijmegen University Hospital, which is in his home town. Prof. de Kleuver’s specific task will be to build a regional Orthopedic & Spine network with the Sint Maartenskliniek (where he currently works) and with the neurosurgeons. Together both groups will form the largest Orthopedic & Spine group in The Netherlands. His new appointment will begin October 1, 2016.

Historical Committee Update

George H. Thompson, MD
SRS Historian

The committee will be conducting videotaped interviews with numerous individuals at the 51st Annual Meeting & Course in Prague, Czech Republic. This is in an effort to bring our video archives up to date and to add to our collection of interviews with significant influencers in the field of spine deformity. Scheduled interviews include Randal Betz, MD; Alvin Crawford, MD; Ronald DeWald, MD; Jean Dubousset, MD; John Kostuick, MD; Lawrence Lenke, MD; John Lonstein, MD; Richard McCarthy, MD; James Ogilvie, MD; Acke Ohlin, MD, PhD and Harry Shufflebarger, MD.

The Van Loon specimen is an adolescent idiopathic human spine specimen that was operated using Harrington Rod Instrumentation. The patient died nine months postoperatively and the spine was harvested.  The current owner, Dr. Piet Van Loon, is donating this specimen to the Harrington Archives, which are also housed at the University of Kansas Medical Center Archives with the SRS Archives. Dr. Van Loon will be presenting this donation to a representative from the Harrington Archives during the Opening Ceremonies of the Annual Meeting. As always, I highly encourage all of our members to visit the SRS and Harrington Archives as they are very interesting and informative. Please contact the SRS Office for more details on how to arrange a visit.

As previously noted, the timeline used for the SRS Museum has been made digital in more ways than one! First, visitors to the SRS website can take a virtual tour of the actual museum, http://www.srs.org/virtual-museum/am15/index.php. Additionally, the timeline has been made into a living digital timeline, http://www.srs.org/historical-timeline/. Currently, only items from the museum are listed on this timeline. The committee will be working on adding to the digital timeline over the next few years. In order to make this timeline as accurate and comprehensive as possible, the committee will be reaching out to the individuals directly related to timeline topics to provide a write-up.

We have been saddened thus far in 2016 by the death of several members.  These include Anthony Bianco, MD; Jimmy S. Daruwalla, MD; John H. Hurley, MD; O. Ross Nicholson, MD; and Klaus Zielke, MD.

Chair: George H. Thompson, MD Committee: Behrooz A. Akbarnia, MD; Jason E. Lowenstein, MD; Terry D. Amaral, MD; Alejo Vernengo-Lezica, MD; Patricia N. Kostial, BSN, RN; Jay Shapiro, MD; Hani Mhaidli, MD, PhD

Treasurer’s Report

J. Abbott Byrd, III, MD
Treasurer

SRS remains in sound financial condition. The data in this report is as of May 31, 2016, and will change by the end of the SRS fiscal year on December 31, 2016, but the information provided yields a glimpse at our financial status almost halfway through the fiscal year.

The total assets of SRS are $12.3 million which is a 3% increase compared to 2015.  Our research endowment is in two main funds.  The first is the $4.4 million REO fund which is managed by the Rockefeller group.  The second is the $3.7 million fund which SRS took in-house from OREF (OREF Legacy Endowment) and is managed by the Vanguard group.  In addition, SRS was scheduled to receive $419,000 from OREF designated giving in June.  The SRS has $3.3 million in cash designated for the operating and research budgets as well as $500,000 in other assets.

The SRS has multiple sources of General Operating income including member dues ($423,000 to date and budgeted for $470,000) and other sources.  The General Operating income to date is $531,000.  The IMAST and Annual Meeting (too early to report numbers), other courses and miscellaneous sources are also usually sources of income.  Total income to date is $1.64 million.  Another large source of income for SRS is corporate donations which are approximately $2 million per year, much of which is to be realized by December of this year.

SRS has multiple line items of expenses too numerous to list but, to date, our total net income is $371,000 and is budgeted to be $100,000 at the end of December which we should meet. 

The research endowment returns are acceptable and as of May 31 were 2.2% for the year.  The market has significantly increased since then and it is expected that the next gains reported will be higher.

As you can see from this brief snapshot, SRS is doing quite well thanks to our strong membership as well as the excellent leadership from our Presidential Line and board members.  I wish to especially thank Daniel A. Nemec, MBA, CAE, from our management team whose job it is to prepare and monitor the SRS financial statements, which has made my job as Treasurer immeasurably easier.

Ethics Corner

Kamal Ibrahim, MD, FRCS(C), MA
Ethics and Professionalism Committee Chair

Is this an ethical issue? The committee publishes in each issue of the newsletter a case for a possible ethical conflict and invites members to send their comments. John Lubicky, MD, wrote the ethical question for this issue. Please send your comments to info@srs.org. The committee will collect all responses, summarize and publish them in the next newsletter.


ETHICAL QUESTION

Recently, The Boston Globe ran an extensive article on the issue of concurrent surgery in one of the country’s most famous and prestigious hospitals. It related the story of one orthopedic surgeon’s routine use of such a practice, presumably condoned or at least permitted by that hospital. Unfortunately, the report recounts one day’s schedule of this surgeon during which two rather complicated cases were ongoing simultaneously and during which one patient suffered a serious complication. It raised the question of whether this practice is ethical and/or safe. It also brings up issues of informed consent and professionalism. Administrators of other hospitals that allow this practice must have been shocked by this exposé and alarmed about the possible repercussions that might arise from this article in the media. However, that article also relates how this is an efficient and effective use of a busy surgeon, minimizing down time, and maximizing throughput of patients thus providing care to more patients. Surely federal, state and private regulatory entities took notice of this report and are probably poised to impose new sanctions, documentation, and penalties on those involved in this practice. Elimination or severely curtailing the practice would certainly have a significant impact on hospitals that currently allow it.

Dr. X is a busy spine and trauma surgeon. On one of his OR block days, he has two ORs available to him. In one room, he typically schedules several elective spine and trauma cases and in the other, he places incoming or leftover trauma cases. He bounces back and forth between the rooms allowing the residents or fellow to position and start cases in one room while he supervises/performs the critical parts of cases in the other. In between, he goes to the pre-op area, signs the site, and greets the subsequent patients. While he does not specifically explain the operating arrangements, i.e. “concurrent surgeries in which trainees will be doing significant portions of their surgery without him being physically present for the entire procedures”, his patients do know that they are at a teaching hospital and that trainees will be participating in their care (whether they truly understand that concept or not). To be fair, the cases are generally staggered rather than truly concurrent in the usual sense, but this arrangement makes for great efficiency allowing him to complete 10 or more cases in a day though the operating day may last into the evening before all cases are completed.

Although this arrangement has been working well for many years and has not been a source of patient complaints or malpractice issues, is this practice ethical? Or, should he be required to have a more formal disclosure of this practice?

Please send your opinion to info@srs.org. The committee will review all responses and publish their summary in a subsequent newsletter.

Chair: Kamal N. Ibrahim, MD, FRCS(C), MA Committee: Brian G. Smith, MD; Oheneba Boachie-Adjei, MD; Paulo J.S. Ramos, MD; M. Wade Shrader, MD; John P. Lubicky, MD, FAAOS, FAAP; Hilali Noordeen, FRCS; Timothy S. Oswald, MD; James M. Eule, MD; Timothy A. Garvey, MD; H. Robert Tuten, MD    

 

Nominating Committee

John P. Dormans, MD, FACS
Nominating Committee Chair

The nomination period was from December 1, 2015, to March 1, 2016. All SRS members were invited to nominate members for the following positions: Vice-President, three Directors At-Large for the Board of Directors, and a Fellowship Committee member. We received an outstanding number of nominations for these positions and the Committee has subsequently reviewed and considered the large list of qualified candidates.

All potential candidates were contacted by the Committee Chair to clarify the position duties and to confirm the candidates’ commitment to serve. The final nomination list has been completed and presented to the Board of Directors, for information only, at the IMAST meeting in Washington, D.C., United States in July 2016. The nominees will then be voted upon at the first membership business meeting in September during the 51st Annual Meeting & Course in Prague, Czech Republic.

A proposed list of changes for the nominating process for Board of Directors at-large members has been created. The proposed changes are as follows:

  • All nominees must be Active Fellows in good standing.
  • Nominees for all positions should regularly attend the Annual Meeting & Course and/or IMAST, and should actively participate in and/or contribute to other SRS activities such as research grant applications, endowment contributions, outreach programs, submission or presentation of papers, serving as faculty for courses, participation in committees, submission of M&M data, etc.
  • Nominees for the position of Director at Large should have chaired at least one SRS Committee.
  • At the Nominating Committee’s discretion, those being considered for this position, who are from outside North America or who are ≤45 years old, may qualify with active service on at least four committees, of which a minimum of two were as an Active Fellow.
  • Nominees for the position of Vice President, Secretary-Elect or Treasurer-Elect should have served either as a Director at Large or as a Council Chair.

Chair: John P. Dormans, MD, FACS Committee: Marinus de Kleuver, MD, PhD; John R. Dimar, MD; Kamal N. Ibrahim, MD; B. Stephens Richards, III, MD.

Corporate Relations Committee

John P. Dormans, MD, FACS
Corporate Relations Committee Chair

The committee remains quite active by communicating and meeting regularly with our corporate supporters. Dr. Dormans along with Todd Albert, MD and David Polly, Jr., MD, met with Globus Medical in mid-February to discuss plans to move to Double Diamond Level.

The goal is to expand the list of SRS corporate supporters and to maintain and increase their level of support. Our team has been quite successful with this effort and the total support will be similar to the amount for 2015, or around $2.25 million. As of June 15, a total of $2.08 million has been committed.

Chair: John P. Dormans, MD, FACS Committee: Steven D. Glassman, MD; Mark Weidenbaum, MD; Frank J. Schwab, MD; David W. Polly, Jr., MD; Kenneth K.C. Cheung, MD; J. Abbott Byrd, MD.

Long Range Planning Committee

John P. Dormans, MD, FACS
Long Range Planning Committee Chair

Montreal, Canada was approved as the location for the Annual Meeting & Course in 2019 and contract negotiations are nearly completed. Amsterdam, Netherlands was approved in July as the location for IMAST 2019 and contract negotiations are underway.

Hamburg, Germany was felt to be a very good option but was unavailable due to renovations scheduled in 2019. The committee believes it should be considered for a future meeting. Seattle is being considered for the 2020 Annual Meeting.

Upcoming Meetings:

2017 – IMAST: Cape Town, South Africa  Annual Meeting: Philadelphia, PA, USA
2018 – IMAST: Los Angeles, CA, USA  Annual Meeting: Seoul, Korea
2019 – IMAST: Amsterdam, Netherlands  Annual Meeting: Montreal, Canada
2020 – IMAST: should be outside North America  Annual Meeting: should be in North America‚Äč

Chair: John P. Dormans, MD, FACS Committee: Steven D. Glassman, MD; David W. Polly, Jr., MD; Marinus de Kleuver, MD, PhD; Ferran Pellisé, MD, PhD; Henry F. Halm, MD; Ronald A. Lehman, Jr., MD

IMAST Committee Update

Ronald A. Lehman, Jr., MD
IMAST Committee Chair

We have just concluded our highly successful 23rd International Meeting on Advanced Spine Techniques (IMAST) held in Washington, D.C. July 13-16, 2016.  We had over 870 registrants and 570 delegates attend the meeting, and we have already begun to focus on our 24th IMAST meeting to be held in Cape Town, South Africa from July 12-15, 2017. With the help of Henry F. H. Halm, MD, IMAST Co-Chair and local host Robert Dunn, MD, we anticipate an outstanding venue and program.  Cape Town has much to offer in terms of culture and history, with many nearby National landmarks allowing the entire family to enjoy its beauty. We hope that members and their families will attend in record numbers, as it is on many people's “bucket list” of places to visit.

In conjunction with the Program Committee, the IMAST committee reviewed 1,541 abstracts for this past meeting.  We selected 179 four and two-minute podium presentations.  In addition, we had an exciting educational program, featuring symposia on health care reform and safety, and “Novel Technologies and Techniques in Spine Surgery” that were well received. Each abstract was reviewed by 5-7 different reviewers in a blinded fashion and then graded on both an Olympic format (similar to Olympic judging) as well as average grade format.  We found over the past decade that the Olympic format allows for bias to be minimized, and generally results in quality scoring.  Interestingly, half of all abstracts were submitted from outside of North America with half of all presentations presented by international members and delegates.  This has truly become a global Society.

There were 17 Hands-On Workshops (HOWs), and 29 exhibit spaces that were filled by 19 companies.  Many of these HOWs were “standing room only”, and generated some very interesting debates and discussions.  We will continue to expand this aspect of our sponsored, educational component moving forward. 

In addition, Dr. Halm and I reviewed the suggestions and course feedback.  As a result, we have already met with the Presidential Line (PL), and will continue to focus our Educational Program by decreasing the number of concurrent sessions.  While the past several years have allowed us to disseminate a tremendous amount of educational content, some members felt that they “missed out” on all of the opportunities and symposia.  As always, SRS and the IMAST Committee are committed to meeting the needs of our membership.

I would personally like to thank our President, David Polly, Jr., MD, and the other members of the Presidential Line for their support and guidance through this process.  I would like to thank Henry Halm, MD for his assistance and partnership with the endeavor.  Also, the staff at SRS, Ann D’Arienzo, Courtney Kissinger and Tressa Goulding, have been invaluable.

Finally, we owe a debt of gratitude to the IMAST Committee, Program Committee and ad hoc reviewers for their tireless work in assisting with the grading of over 1,500 abstracts.

Chair and Co-Chair:  Ronald A. Lehman, Jr., MD and Henry F. Halm, MD Committee Members:  Christopher I. Shaffrey, MD; Lawrence L. Haber, MD; Jacob M. Buchowski, MD, MS; Justin S. Smith, MD, PhD; Dean Cho, MD; Meric Enercan, MD; Nicholas D. Fletcher, MD; D. Kojo Hamilton, MD, FAANS; Roger K. Owens, MD; Andrew H. Jea, MD; Jeffrey Dean Coe, MD; Yong Hai, MD

Research Grant Committee Update

Michael K. Rosner, MD
Research Grant Committee Chair

Research and Education remain the principle lifeline of our society.
The Research Grant Committee received 20 grant applications in the spring cycle (April 1, 2016) that were reviewed and considered for funding. The research committee consists of 26 members who each reviewed approximately 6-7 grants for a designated team. The research committee is deeply appreciative of the support provided by Ashtin Neuschaefer, SRS staff liaison, for her continuous work to make the review process smooth and timely. 

This spring the research grant committee awarded the following grants totaling $70,000.00:

Title of Project

Pr. Inv/Co Inv.

Amount Requested

Type of Grant

Amt. Approved

Biomechanical in vitro comparison of pedicle subtraction osteotomy (PSO) and anterior column release (ACR) for severe sagittal imbalance correction

Dr. Luigi La Barbera

$25,000.00

SRS-Globus NI

$25,000.00

3D modeling for magnetically controlled growing rods

Dr. Jason Pui Yin Cheung

$24,996.00

SRS-Globus NI

$15,000.00

Use of Ultrasonic Bone Scalpel in Adolescent Idiopathic Scoliosis - Randomized Clinical Trial

Dr. Sumeet Garg

$25,000.00

SRS-Globus NI

$10,000.00

The Ultimate Patient Reported Outcome: Validation of the Patient Generated Index (PGI), Risk Aversion (RA) and Decision Regret (DR) Questionnaires in Adolescent Idiopathic Scoliosis (AIS)

Dr. Baron S. Lonner

$50,000.00

SRS-Globus SI

$20,000.00

The new application cycle has opened for the fall cycle and will close October 1, 2016. 

A Research Outcomes Sub-Committee has been reviewing progress reports, final reports, and extension requests from past grant winners. In each case, the committee decides whether to release funds as per the initial grant, or request further data or, as in the case this year, to withhold further release. Investigators need to be aware that considerable scrutiny and discussion takes place before the decision is made to release the funds, and the decisions are made much easier by the investigators submitting a detailed report in the required format.

Michelle Marks, PT, MA continues to lead the charge on post final report follow up to provide data on what has been produced from the funds provided by SRS.

The Lunchtime Symposium at the Annual Meeting & Course has been accepted. We have invited presentations from SRS research grant recipients that represent a range of scientific areas. Below you will find the agenda for the Lunchtime Symposium on September 23 at 12:00pm in Room, Meeting Hall

12:00 – 12:05pm 
Introduction
Patrick Cahill, MD

12:05 – 12:15pm
What is the Clinical Significance of Measuring Lumbopelvic Position?
Ann M. Hayes, PT, DPT, OCS

12:15 – 12:25pm
Study of Neural Connectivity, Functional Activation and Grey Matter Volume of the Sensorimotor Network in Idiopathic Scoliosis
Julio Domenech Fernandez, MD, PhD 

12:25 – 12:35pm
Biomechanical Evaluation of a Dynamic Stabilization System for Prevention of Proximal Junction Kyphosis (PJK)
Dilip K. Sengupta, MD

12:35 – 12:45pm
The Efficacy and Pharmacokinetic/Pharmacogenetic Profile of Intravenous Tranexamic Acid in Decreasing Blood loss in Pediatric Idiopathic Scoliosis Surgery
Michael T. Hresko, MD

12:45 – 1:00pm  Discussion

Development Committee Update

Serena S. Hu, MD
Development Committee Chair

The Scoliosis Research Society has long been aware of the strong roots that spine deformity fellowships have provided for spine surgeons worldwide.  Many have gone on to found spine fellowships, multiplying the impact that these training programs have had.  The Development Committee is working to memorialize the “Genealogy” of our members. 

We will be contacting our members who have spine deformity fellowships, both adult and pediatric, US and outside of the US, to help assemble lists of fellows who have completed their fellowships.  Tracking where fellows have gone, to help other fellowships grow, to start their own fellowships, to have busy practices, will result in the development of a “Genealogy Tree” where we can view the many instances of branching and cross-fertilization in our collective experiences.  We hope that this Genealogy Tree will be of interest to the membership, rekindle relationships and also serve as a foundation for challenge grants.

The Development Committee had a very successful fundraising drive for the 50th Anniversary of the Annual Meeting of SRS.  Under John Dimar, MD’s leadership, $250,000 in member donations and over $110,000 was raised by the auction at the Annual Meeting banquet.  Thanks to all for donated the valuable items and unusual and unique experiences as well as to our members who won their bids!

We continue to build our Research, Endowment and Outreach (REO) Fund to enable our Society to plan for future research grants, member activities and international outreach.  Our membership dues and meeting registration only cover about 43% of our operating expenses. While industry support has been very helpful in the past, increasing scrutiny has led to more challenges with this in recent years and may lead to declining support. Thus, to continue our mission, we need to increase our donor support from our dedicated membership.

Chair: Serena S. Hu, MD Committee: John R. Dimar, II, MD; John P. Dormans, MD; Kamal N. Ibrahim, MD, FRCS(C), MA; Paul D. Sponseller, MD, MBA; Robert W. Gaines Jr., MD; Lloyd A. Hey, MD, MS; Jeffrey D. Coe, MD; Steven D. Glassman, MD; John A.I. Ferguson, FRACS; Panagiotis G. Korovessis, MD, PhD; Steven M. Theiss, MD; J. Abbott Byrd III, MD; Dean Chou, MD; Saba Pasha, MD; Hilali H. Noordeen, FRCS

Global Outreach Committee Update

Ferran Pellisé, MD, PhD
Global Outreach Committee Chair

During 2016, the Global Outreach Committee has worked hard to accomplish the committee charges and develop its main priorities: a GOP Road Map, a new online GOP database and a GOP paper describing one year’s activity at various SRS GOP sites.

The GOP Road Map has been discussed and agreed upon with committee members and GOP site leaders. Three site categories will be considered: Endorsed, Recognized, and Self-Sufficient/Self-Sustainable. Categories within the road map have been defined based on site infrastructure, surgical activity, and commitment (reporting and membership). Increasing SRS endorsement and paralleling road map progress are being considered by the Board of Directors. 

GOP Site Category
(Definition)

Infrastructure

Surgical Activity

Reporting

SRS (Educational) Endorsement

RECOGNIZED
Initial level

Stable ortho or neurosurgical infrastructure

Acceptable infrastructure for perioperative surgical deformity care

No spinal deformity surgery outside SRS-GOP missions

At least 10 deformity cases done in mission trips during the last 2 years.

Synthesized site general information to display on SRS webpage

Mission Trip yearly plan and reports

GOP individual patient dataset reports

1 “e-news” article with photos / year

yearly conference call with GOP Com Chair

Representation on the SRS GOP webpage

ENDORSED

Above criteria

Eventually: Stable spine surgery infrastructure +/- IONM

Minimal or No spinal deformity surgery outside SRS-GOP missions

Above mentioned reporting duties performed regularly at least 2 years in a row

Submit at least one patient story / year

Preferred status to award meeting scholarships

SRS endorsement to attract comercial support/sponsorship

Invited to “recruit” at GOP table

SELF-SUSTAINABLE
Self-Sufficient

Stable spinal deformity infrastructure

IONM

SRS candidate or active member

Basic spinal deformity surgery performed regularly

SRS-GOP mission trips for complex cases

Above mentioned reporting duties

Submit an abstract to IMAST or Annual meeting

Above mentioned endorsement

“1 year GOP fellowship award”

Considered for educational activities (WWC / Curriculum)

SRS membership fees for locals adjusted to local cost of living

Definitions:

  • Stable Ortho or Neurosurgical infrastructure: Site has the minimal infrastructure (OR and immediate postoperative care equipment) required to perform general orthopedic or neurosurgical activity safely. >50 ortho or neurosurgical cases/year done safely.
  • Stable Spine Surgery infrastructure: Site performs >24 spine surgeries / year safely (with or without IONM)
  • Stable Spinal Deformity infrastructure: Site performs >24 deformity surgeries / year safely (IONM)
  • GOP Patient Report Dataset: Core dataset individual patient parameters to be uploaded in the SRS GOP website database
  • Yearly Mission Trip plan and Report: Online report describing performed and planned outreach mission trips, mission attendees, medical and educational activities, general non-medical issues of interest.
  • SRS Scholarships / awards
  • SRS courses (WWC / Curriculum)

A simple, practical, M&M-compatible, online GOP database is being developed. This “basic” database will replace trip reports and become the prospective registry of SRS GOP activity. It should be ready to be piloted by the SRS Annual Meeting & Course in Prague and ready to use by January 2017. The GOP paper will be based on the prospective 2017 data gathered online by the new database.

At the Annual Meeting & Course in Prague, the GOP Lunchtime Symposium will be a combined session on safety issues with the Safety Committee and involve past GOP committee members and current site leaders. This symposium will also be offered as a webcast on Friday, September 23, 2016, from 12:00-1:00pm CET (10:00-11:00am GMT/UTC, 6:00-7:00 am EDT) for those who are unable to attend. For more information on the webcast, visit http://www.srs.org/meetings/am16/webcast/.

We actively seek the participation of all SRS members in our outreach program. Margaret Mead said, “never doubt that a small group of thoughtful, committee citizens can change the world; indeed, it’s the only thing that ever has.” Please take a look at the new updated interactive world map including all our sites and come to the combined Lunchtime Symposium on Safety to interact with site leaders and network. Members who want to propose new sites are invited to join the committee meeting Tuesday, September 20 at 11:30am at the Prague Congress Centre.

The GOP Committee wants to publically thank SRS staff liaison, Lily Atonio, for the superb job done all over the year providing advice, input and contributing to the development of the above-mentioned committee projects.

With deep regret do we announce the passing of Tarik Fikry, professor of orthopaedic surgery at Hôpital Ibn Tofaïl in Marrakech, Morocco. Dr. Fikry had been actively involved with the SRS programs in Morocco. He was the local director of the Global Outreach site in Marrakech since its acceptance into the program, and recently co-chaired the SRS-WWC in December 2015. He will be sorely missed.

Chair: Ferran Pellisé Urquiza, MD, PhD  Committee: Anthony S. Rinella, MD; Federico P. Girardi, MD; Yongjung J. Kim, MD; Marinus de Kleuver, MD, PhD; Dheera Ananthakrishnan, MD, MSE; Daniel P. Borschneck, MD, BSc, MSc, FRCSC; Charla R. Fischer, MD; Nanjundappa S. Harshavardhana, MD, MS, DO; Mauricio Montalvo, MD; J. Naresh-Babu, MS, FNB(Spine); Denis Sakai, MD; Ricardo A. Santos, MD; Saumyajit Basu, MD; Gregory M. Mundis, MD; J. Michael Wattenbarger, MD; Phyllis d’Ambra, RN, MPA; Andrew G. King, MB,ChB, FRACS,FACS; Elias C. Papadopoulos, MD; Edward P. Southern, MD; Vidyadhara Srinivasa, MS, DNB, FNB (Spine)

Coding Corner: Modifier 59

Matthew D. Hepler, MD
Coding Committee Chair

Introduction

There has been a significant increase in the number, breadth, and depth of spine procedures performed in the United States in the last two decades and, concomitant with these trends, an increasingly complex coding system for documentation and billing. This complexity combined with enhanced payor scrutiny has resulted in more audit activity, more claim reviews and denials, and more administrative burden. One of the most common billing errors is the improper use of modifiers and in the 2014 CMS (Centers for Medicare and Medicaid Services) identified modifier 59 as the most widely used and abused modifier leading to reviews, appeals, and allegation of civil fraud. This article will review the development and importance of modifier 59, explain its intended purpose, outline guidelines for its proper use, and discuss most recent CMS updates and guidelines.

History of CPT and Modifiers

CPT (Current Procedural Terminology) was first developed by the AMA in 1966 as a comprehensive list of bundled physician procedures. In 1983 HCFA (The Health Care Financing Administration, now the CMS) merged updated versions of CPT with its own HCPCS (Healthcare Common Procedure Coding System) to encompass all Medicare billing. Since that time, CPT has been maintained by the AMA through an editorial panel that meets each year to revise or delete old codes or add new codes which are then listed in the annually published CPT manual.  CMS uses the CPT codes as a basis for physician payment in the current fee-for-service system. Modifiers were introduced in 1992 to provide more details of coding scenarios (multiple procedures, staged procedures, return to OR, etc). Modifier 59 was added in 1997 to indicate when a procedure is distinct and independent from other services performed on the same day.  It soon became the most commonly used modifier prompting an OIG (Officer Inspector General) audit in 2005 which concluded 40% of Modifier 59 use was inappropriate resulting in $59 million in improper payments. It's been called the “unbundling” modifier and CMS believes it is used incorrectly to  “unbundle” procedures and bypass NCCI (National Correct Coding Initiative) edits resulting in double billing.  Understanding NCCI edits are fundamental to appreciate the development and proper use of Modifier 59.

NCCI edits

NCCI refers to National Correct Coding Initiative Edits. In 1995, a Government Account Office report found hundreds of millions of dollars in Medicare expenditures were the result of waste, fraud, and abuse. In response, Congress software mandated development to detect “unbundling”: billing of multiple procedures when one procedure/code would be appropriate. NCCI edits were developed to curb this coding abuse and these edits apply only to services which are provided by the same provider, on the same patient, on the same day; they apply to all physicians who bill for Medicare although third-party payers may also use NCCI edits.

The CCI edits consists of a list of CPT code “pairs” which generally should not be reported together by a provider on the same day of service. These code pairs are reported as Column 1 and Column 2 codes and CMS considers the column 2 codes to be a subset or inclusive of column 1 codes; in general, reporting both codes is inappropriate and constitutes full billing for separate codes which likely contain overlapping work. For example, 63030 (lumbar laminotomy) should generally not be billed with column 1 code 63047 (lumbar laminectomy) based on the CPT definition of these procedures since laminotomy is a subset or part of a laminectomy (Table1). There are circumstances when submitting both these codes is appropriate and CCI edits identify this possibility with the indicator “1” (column 5 of Table 1). For example, if a laminectomy (63047) is performed at 1 level and laminotomy (63030) at another level, submitting both codes is appropriate and identified by appending the appropriate modifier (in this case modifier 59) to indicate this is a distinct, separate procedure performed at a different anatomic site and therefore should be reimbursed. An indicator of “0” in the edit stipulates a modifier cannot be used to override the CCI edit in any circumstances. For instance, the NCCI edit for 63047 (laminectomy) and 62319 (injection, including indwelling catheter) has the indicator “0” and these codes should never be billed together as anesthesia is always included in the surgical procedure. There are other modifiers which can be used to override CCI edits and some of the more common ones include 25 (separate EM service), 50 (bilateral procedures), 58 (staged procedures), 59 (separate/distinct procedures), 76 (repeat procedure), 78 (return to OR for related procedure), 79(return to OR for unrelated procedures). A modifier should not be used to override a CCI edit unless the two procedures represent different sites, different encounters/operative sessions, separate anatomic locations, or a distinct service recognized by coding conventions.

Modifier 59

Modifier 59 was developed to identify procedures or services which are distinct or separate and not usually reported together, but may be appropriate under specific circumstances. The CPT manual defines Modifier 59 as follows:

“Distinct Procedural Service:  Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. If no other descriptive modifier is available and the use of modifier 59 best explains the circumstances, should modifier 59 be used? Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

It is important to recognize that modifier 59 was developed for the rare occasion when there is an exception to a CCI edit and CMS, therefore, believes it should only be used when there is a permissive CCI edit. For example, a surgeon injects the right knee and right shoulder of the same patient on the same day. This combination should be reimbursable as two procedures are performed at different sites. There is only one code (20610 which is used twice) and no code combination CCI edit and in this situation, CMS does not want modifier 59 used. Similarly, modifier 51 can’t be used (there are not multiple stand-alone codes) and modifier 50 cannot be used (it is not a bilateral procedure). As a result, CMS recommends using modifier 76. This, however, is not a CPT rule and some private payors may not only allow but actually prefer using modifier 59 in this situation; check each carrier regarding policy and interpretation of 59.

Another important point to remember is modifier 59 should only be used when another established modifier does not better describe the scenario. 59 should be the modifier of last resort. If bilateral (50), multiple (51), staged (58), repeat (76), or other procedure modifiers can describe the procedure they should be used, not modifier 59. A common example is a multilevel interbody procedure performed with interbody “cage“(intervertebral mechanical device) used in ALIF, XLIF, or T/PLIF procedures. In this situation, there is no add-on code as there is for both the fusion and decompression procedures and it is not a stand-alone procedure (in which case the multiple procedure 51 modifier could be used). Therefore, modifier 59 best explains this “distinct procedure” and would be appropriate. It should not be used for a second device at the same level (2 cages in one interspace) as that would not be a separate and distinct procedure.

One of the more common uses of modifier 59 is to identify a procedure performed at a different anatomic site especially if it represents a different lesion or injury. As the example above demonstrated, it would be appropriate to bill 63047 (lumbar laminectomy) with 63030-59 (lumbar discectomy) to indicate the procedures were performed at two different levels; these codes would otherwise not be allowed due to the CCI edit that considers laminotomy/discectomy a subset of laminectomy. Modifier 59 would not be appropriate if the second procedure is adjacent to and merely an extension of the initial laminectomy.  Similarly, if a patient underwent a thoracic posterior decompression, fusion and instrumentation (T11-T12) followed by a lumbar decompression, fusion, and instrumentation (L5/S1) at the same encounter through a separate incision it would be appropriate to use 59 to indicate a separate, distinct procedure was performed. The appropriate codes to use would include 22610, 63047-51, 22840 and 22612-59, 63047-51-59, 22840-59. Again, it would not be appropriate to use modifier 59 if the lumbar procedure was adjacent to and an extension of the T11-T12 procedure. Of course, these are uncommon scenarios and would rarely be encountered and reported. 

Another modifier 59 scenario which generates confusion is the use of a laminectomy with posterior interbody fusion. PLIF (22630 and 22633) have CCI edits with the various decompression codes as shown in Table2. These edits have a modifier indicator “1” which allows laminectomy (63047) with PLIF (22630) under certain circumstances. This would include laminectomy at a different anatomic site (PLIF at L4/5 and laminectomy L3) similar to the examples given above for 63047 and 63030. In addition, there are circumstances when these codes (63047 and 22630) can be used at the same level.  CPT defines 22630 as “arthrodesis including laminectomy/discectomy to prepare interspace (other than for decompression). If after performing the PLIF, there is remaining stenosis requiring further decompression (extensive canal stenosis requiring complete laminectomy) it would be appropriate to also code the laminectomy (a separate, distinct procedure at the same level identified with modifier 59) according to CPT rules. However, CMS payment policy (Chptr VIII, section C, paragraph 25) does not allow payment of 63042 or 63047 with 22630 or 22633 as it considers the laminectomy/discectomy inclusive of the PLIF.  It's worth noting modifier 59 does not require a different ICD for each CPT; conversely, different diagnosis is not adequate criteria for use of 59.

In January 2015 CMS, introduced modifiers XE, XS, XP, XU to replace modifier 59. These modifiers were developed to provide more specificity in cases where modifier 59 was previously reported. CMS provides the following definitions:

XE- “Separate encounter, A service that is distinct because it occurred during a separate encounter”
XS-“Separate Structure, A service that is distinct because it was a performed on a separate organ/structure.”
XP-“Separate Practitioner, A Service that is distinct because it was performed by a different practitioner”
XU-“Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”

CMS provided few guidelines to the use of these new modifier subsets and since January 2015, CMS has given instructions to continue using Modifier 59. Each MAC, however, may have its own guidelines and instructions for the use of modifier 59. Stay Tuned…

Summary

In summary, Modifier 59 is used to indicate a service that is a distinct and separate procedure from another service with which it usually would be “bundled” together. It is used when there is a different session, different procedure/surgery, different anatomic site or organ, separate incision/excision, or separate lesion or injury. It has become the most commonly used modifier and CMS has clearly communicated its concern that Modifier 59 is inappropriately used to “bypass NCCI edits,” resulting in coding errors, abuse, and even civil fraud. CMS opines it should only be used if an NCCI edit exists although this is not a CPT rule. Modifier 59 should only be used when no more descriptive modifier is available and modifier 59 best explains the circumstances. The appropriate use of modifier 59 is an unusual circumstance and for these reasons, likely to result in documentation requirements and possible audit.

References

TABLE 1

 Column1 Column2 Effective Date Delete Date

Modifier
0 not allowed
1 allowed
9 not applic

PTP edit rationale
63047 62319 20010701 * 0 Anesthesia service included in surgical procedure
63047 63005* 19960101 * 1 Mutually exclusive procedures
63047 63012* 19960101 * 1 Mutually exclusive procedures
63047 63015 19970101 * 1 Mutually exclusive procedures
63047 63017 19970101 * 1 Mutually exclusive procedures
63047 63020 19970101 * 1 HCPCS/CPT procedure code definition
63047 63030 19960101 * 1 HCPCS/CPT procedure code definition

TABLE 2

 Column1 Column 2 Effective Date Delete Date

Modifier
0 not allowed
1 allowed
9 not applic

PTP edit rationale
22630 63030 19990101   1 Standards of medical / surgical practice
22630 63042 20140101 * 1 Misuse of column two code with column one code
22630 63047 19990101 * 1 Misuse of column two code with column one code

Chair: Mathew D. Hepler, MD Committee: Christopher J. DeWald, MD; Nigel J. Price, MD; Samuel S. Bederman, MD, PhD, FRCSC; Shay Bess, MD; Barton L. Sachs, MD, MBA, CPE; Michael S. Chang, MD; R. Dale Blasier, MD; Richard J. Haynes, MD

Morbidity & Mortality Committee Update

Jose A. Herrera-Soto, MD
Morbidity and Mortality Chair

The Morbidity & Mortality Committee has worked this year to improve the ease of use, utility, and relevance of the SRS M&M database. The database is central to the goal of determining the rate of complications associated with the surgical treatment of spinal deformity, and the committee owes a debt of gratitude to the Fellows of SRS, whose enthusiastic participation in the submission of their case data has made the database the success that it is.

Speaking of participation, in 2015, 735 of 874 (84%) fellows submitted a total of 48,366 cases. Participation in data submission has varied widely over the years, but 2015 has been the most participative in the last three years. We still had a group of 99 Active Fellows who decided to pay the $300 research fee and not submit; however, the committee would much prefer to have your data than your money, so please do not let your desire to contribute financially to the SRS’s research mission dissuade you from submitting your data!

This year, members who did not submit cases by the deadline were asked to complete a survey to receive an extension to submit data. 34 Active Fellows and 20 Candidate Fellows participated in the survey and took advantage of the extended deadline to submit data which was key to increase submission rates for this past year. The survey asked five simple questions to help us learn why members did not submit by the April 1 deadline and also to help us improve users’ experience with the M&M site. The value of the SRS M&M database depends completely on participation by SRS members. To that end, the committee eagerly seeks feedback from the membership on ways to improve the ease of data submission and enhance the accuracy and validity of the data submitted. As part of the M&M submission improvement plan, we will now send reminders on a monthly basis.

In regards to the Request for Proposals, so far we have received and approved two requests in 2016.

Thank you for all who diligently submit their M&M data reports!

Chair: Jose A. Herrera-Soto Committee: Jonathan E. Fuller, Past Chair, Aruna Ganju, Joseph M. Verska, Jeremy L. Fogelson, Steven W. Hwang, Seung-Jae Hyun, Sergio A. Mendoza-Lattes, William F. Young, Kathy M. Blanke, Ian W. Nelson, Chair-Elect, Christopher J. Bergin, Vicki Kalen, Darrell S. Hanson, Peter B. Slabaugh and Jeffery D. Thomson.

Save the Dates for 2016 SRS Meetings!

To view future SRS meetings and other spine associations and societies' meeting, visit http://www.srs.org/professionals/conferences-and-meetings/calendar

Mark your calendars for the following future meetings:

51st Annual Meeting & Course: September 21-24, 2016 – Prague, Czech Republic
Prague Congress Centre
Advanced Registration Closed!
Onsite registration available:
Tuesday, September 20 - 2:00-6:00pm
Wednesday, September 21 - 6:30am-6:00pm
Thursday, September 22 - 6:30am-4:30pm
Friday, September 23 - 6:30am-5:30pm
Saturday, September 24 - 6:30am-12:45pm

2016 Spine Deformity Solutions: A Hands-On Course Schedule

7th Spine Deformity Solutions: A Hands-On Course
From the Asia Pacific Spine Society and the Scoliosis Research Society
October 28-30, 2016 • Hong Kong
Registration Closed! Course Sold Out!

SRS Worldwide Courses

Santiago, Chile
In conjunction with Chilean Spine Society
November 16-17, 2016

Kyoto, Japan
In conjunction with Japanese Scoliosis Society 50th Anniversary Meeting
November 17-19, 2016