President's Message

PREVIEW:
52^nd Annual Meeting and Course in Philadelphia, Sept. 6 to 9

For the past 51 years, the Annual Meeting has been the flagship event of our society, and a meeting that spinal deformity surgeons and scientists from around the world attend to obtain the latest information in this field. The 52^nd Annual Meeting will continue this tradition with a theme on global spine care and innovative educational formats. There were 1506 submitted abstracts; 129 were accepted for podium presentations, 45% of which are from presenters outside of the USA. In addition, we have 104 e-posters, 15 e-presentations, and 12 case discussions. Muharrem Yazici, MD and the Program Committee have done masterful work in reviewing all of the submissions and putting together a truly outstanding program.

New this year are the e-presentations, 15 highly ranked abstracts that could not be included as podium presentations will be recorded and made available on the SRS website after the meeting for additional CME credit. The e-presentation abstracts are also included in the Final Program and are available for viewing on the E-Poster Kiosks.

Praveen Mummaneni, MD and the Education Committee have put together an excellent set of offerings starting with the Pre-Meeting Course, “A Multidisciplinary Approach to Global Spine Care”. After the Pre-Meeting Course on Wednesday will be case discussions followed by the Opening Ceremonies and the Steel Lecture, presented by Michael Smerconish, host of CNN’s Smerconish. He will share with us his perspective on the 2016 US Presidential Election. This promises to be insightful and entertaining.

Thursday morning begins the scientific program, presentation of the Lifetime Achievement Awards to G. Dean MacEwen, MD and Howard H. Steel, MD, and my Presidential Address, with the Half-Day Courses following. Thursday evening will be a wonderful opportunity for you to sightsee around Philadelphia and catch up with friends.

Friday will be a full day of scientific sessions, including the Harrington Lecture, presented by Christopher J.L. Murray, MD, Professor of Global Health at the University of Washington, and author of the Lancet articles on Global Burden of Disease Study. In the evening, the Farewell Reception will be at the National Constitution Center, a beautiful museum with birds-eye views of Philadelphia’s historic landmarks and a rotating collection of rare artifacts celebrating the creation and legacy of the United States’ Constitution. Tickets are required, please come join us for an evening of fun and networking.

New this year for the Saturday half-day, will be a final “highlights session” whereby take-home points from each of the scientific sessions will be presented. So, if you have missed any of the sessions, this would be an excellent time to catch up!

I want to personally thank the committee of local hosts, led by Patrick J. Cahill, MD and including Vincent Arlet, MD; Randal R. Betz, MD; Robert M. Campbell, Jr., MD; David H. Clements, III, MD; John M. Flynn, MD; Peter G. Gabos, MD; Martin J. Herman, MD; Joshua M. Pahys, MD; Amer F. Samdani, MD; and Suken A. Shah, MD. Please take some time during the meeting and enjoy this spectacular and historic city.

All in all, a meeting not to be missed! I look forward to seeing you there.

Treasurer's Report

J. Abbott Byrd, III, MD
Treasurer

The SRS continues to be financially sound.  As of May 31^st of this year our total assets are $13.7M compared to $12.3M in 2016 and $11.9M in 2015.  The breakdown is $5.1M in the Rockefeller (REO) fund, $4.2M in the Vanguard (Legacy OREF Endowment) fund, $3.9M cash (research and operating) and other assets $500K.  Our investments have done quite well this year with Rockefeller returning approximately 12% YTD and Vanguard 8.08% through June 30^th net of fees.  July numbers are not included in the Vanguard return and would certainly increase this return.  In addition, the asset allocation of the two funds differs by design so a direct comparison is not a fair assessment of one fund against the other.  Vanguard is outperforming its benchmarks by 20-30 basis points.  Overall, the SRS investment strategy is working quite well.

General cash reserves were $1.8M at the end of December 2016 which included a $104K net loss in 2016.  This loss was attributed primarily to underperformance of the IMAST meeting in Washington, D.C. where attendance did not meet projections and expenses were high.  As of May 31^st, the general cash reserves have grown to $2.3M but we have budgeted a loss of $155K for 2017.  Again, this is due primarily to the performance of the IMAST meeting which was just held in Cape Town.  However, it is too early to determine the exact fiscal performance of the meeting as all of the expenses have not been paid.  We are looking forward to a well-attended Annual Meeting in Philadelphia which historically has been profitable for the SRS and will help to minimize other losses.

The membership continues to be generous in its donation to the SRS.  As of May, approximately $50K has been donated to support our mission of research, education, and outreach.  I am looking for this to increase as traditionally the bulk of our donations have been made in December as part of tax planning for year’s end.  Serena Hu heads our Development Committee and has an exciting Legacy-Spine Family Tree effort in the works and I encourage you to generously support this effort.

Aside from my routine duties as Treasurer, I have two projects that I am working on.  The first is looking at where our general reserves of $2.3M are being held.  Though the SRS has these assets in several locations the amount exceeds that of funds protected under the FDIC insurance plan.  Dan Nemec, of EDI, and I are looking into other options that would provide protection yet ready access to these monies.  Secondly, I am heading a small subcommittee that is doing “rainy day” planning should our revenue streams decrease in the future.  While the SRS leadership does not anticipate this will happen it is always prudent to “hope for the best and plan for the worst.”

It is a pleasure to serve as Treasurer for the SRS and if you have questions please don’t hesitate to contact me.  In addition, I would like to give a special thanks to Dan Nemec for his invaluable assistance in my role as Treasurer.

Ethics Corner

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

The committee publishes in each issue of the newsletter a case of possible ethical or professionalism dilemma and invites members to send their comments. Please send your comments to info@srs.org. The committee will collect all responses, summarize and publish them in the subsequent newsletter.

In this issue Tim Garvey, MD presents an ethical dilemma that could be faced by any surgeon and was not previously explored.

Two cases recently presented ethical challenges regarding never speaking derogatorily about peers out loud with patients and their families during consultations. Cambridge dictionary defines derogatory as, “showing strong disapproval and not showing respect”. In both cases we felt obliged to be open, and inform the patients that the medical advice that they received, was sub-standard. It was not, that we just “respectfully disagreed”, but that rather, we believed that the treatment recommended was truly not appropriate.

Case 1:
A 45 year old millwright had a 7 month history of classic  right S1 radicular pain, with a positive SLR, a right sided HNP at L5-S1, 80% right leg pain, 20 % LBP, and failure of non-operative care. He sought our 2^nd opinion. He had NO deformity on standing radiographs. His MRI did additionally show Modic endplate changes at L3-4 and L5-S1. His 1^st surgical consult read, “In my hands, he would be best treated with Smith-Peterson osteotomies, and a 2 level AP fusion.” We performed a micro-discectomy and the patient is doing well. We stated to the patient that the proposal “did not make sense”, as there was no objective deformity on which to perform “an osteotomy”, and that a fusion was not indicated, especially a two level A/P, where there was potential 3 level MRI changes.

Case 2:
An 83 year old man with classic pseudoclaudicatory back and leg pain, had multilevel stenosis and spondylosis on imaging. His walking was limited to one block, and sitting was comfortable. He had neurosurgical consultation, which led to his having a 4 level discogram, with all levels rated at 7/10 or higher. In a non-sequitur, a 2 level fusion was recommended. We openly opined that while the discogram was in general “not absolutely contraindicated”, we did not believe in this case that it should have been done, and that the recommendation for fusion was not at all appropriate. If any surgery were to be considered, a decompressive procedure may be an option. This led to the family questioning why an expensive and painful test had been performed, and we acknowledged that we believed that the testing was not appropriate, and that it should not have been done.

In both cases, with fellows present, we did note openly what would be perceived as derogatory statements, i.e. not gratuitously demeaning, but not specifically respectful, concerning surgical care. In both cases, we sent copies of our consults to the original surgeon who gave the 1^st opinion. There is an effort now to develop standardized language by peer review committees with respect to competing surgical opinions, with specific thought as to being respectful, and to medico-legal implications.  However, in what most SRS members would find as egregiously flawed treatment recommendations, should we, “Never speak ill” of our peers?

Comments from some of the committee members:

• One has to remember that, it is a fine line between questioning others’ opinion and making derogatory remarks, which will reflect badly on the surgeon himself (don’t do unto others what you don’t want to be done to you)
   
• In the U.K. We now have mandated multidisciplinary meetings (usually neurosurgery, Orthopedic, oncology, radiology and pain physician) to discuss any case where the proposed treatment is more complex than a one level fusion. Although the funding is not yet absolutely dependent on this process yet, it is intended to be in the future (for both public and private funded patients).
  
  We already experience some areas of concern in how to phrase the recommendation of the MDT in the permanent record. We are aware of the need to reflect a variety of opinion - sometimes strongly felt- without prejudicing the professional standing of colleagues or undermining a future medico-legal defense position should a complication arise.
  
  Careful and non-emotive use of language is required. I have considered the need to perhaps create a stock of standard phrases to reliably reflect opinion in a non prejudicial way.
  
  For example, in the described cases we might have recorded
  "Opinion was divided"
  "Higher risk surgical options should be reserved for a revision surgery"
  "The additional benefit of fusion is not clearly established in this case"
   
• These are good cases to present & we all face these scenarios from time to time. Did the 2nd opinion surgeon & trainees simply inform the patients that they felt the original advice was inappropriate or did they openly belittle the 1st surgeons in the presence of the patients? The former is not derogatory on its face, the latter certainly is.

Chair: Kamal N. Ibrahim Committee: John P. Lubicky, Hilali Noordeen, Brent D. Adams (C), Jason Bernard (C), Ryan D. Muchow (C), Timothy S. Oswald, James M. Eule, Timothy A. Garvey, H. Robert Tuten, B. Stephens Richards III, Jochen P. Son-Hing

Nominating Committee Update

David W. Polly, Jr., MD
Nominating Committee Chair

The first step for the Nominating Committee was to issue a Call for Nominations to members, asking for nominations for the positions of Vice President, Secretary Elect, Research Council Chair Elect, three Directors at Large (one of whom should be age 45 or younger, if a qualified candidate is available), and one member of the Fellowship Committee. Nominations were open from December 1, 2016 to March 1, 2017, with a large number of very qualified individuals nominated.

In addition, the committee each year reviews a list of potential candidates who have fulfilled basic criteria for service on the Board of Directors. Those include:

• All nominees must be Active Fellows in good standing
• Nominees for the position of Director at Large or Council Chair Elect should have chaired at least one committee
• Nominees for the position of Vice President, Secretary Elect or Treasurer Elect should have served on the Board as either a Director at Large or Council Chair
• All nominees should also regularly attend SRS meetings and courses and actively participate in and/or contribute to other SRS activities such as research grant applications, M&M submissions, committee involvement, submission of abstracts, serving as faculty, REO donations, etc.

Although the committee generally tries to select from those nominated by the members, policies state that they may go outside that list in order to select the most qualified candidates. In most years, including this one, those nominated by the members are well qualified and selections are made from that list. Once the top choices have been made, the Chair contacts them to make sure they understand the commitment required and are willing and able to serve.

After extensive discussion, the committee is pleased to present the following slate for a membership vote on Thursday, September 7 during the Members Business Meeting in Philadelphia:

• Vice President – Paul D. Sponseller
• Secretary Elect – Laurel C. Blakemore
• Research Council Chair Elect – Marinus de Kleuver
• Directors at Large: Ron El-Hawary, Lori A. Karol, Rajiv K. Sethi (Under 45)
• Fellowship Committee: Jeffrey D. Coe

Chair: David W. Polly, Jr. Committee: Ahmet Alanay, Serena S. Hu, Lawrence G. Lenke, Stefan Parent

Long Range Planning Committee Update

David W. Polly, Jr., MD
Long Range Planning Committee Chair

The Long Range Planning Committee is charged with selecting locations and venues for the Annual Meeting and for IMAST. This year the committee was looking for 2020 locations in North America for the Annual Meeting and outside North America for IMAST. The committee looks carefully at a variety of factors, including amount of space, layout or “flow” of the space, hotel options, air access, cost and general appeal.

Austin, Denver, Phoenix, and Seattle were all proposed for the Annual Meeting with Auckland, New Zealand, Sydney, Australia and Santiago, Chile suggested for IMAST. Requests for Proposals were distributed to all venues. No venues with adequate space were available for requested dates in Austin or Denver. A new convention hotel in Seattle was, unfortunately, too far behind schedule for consideration this year. There were, however, several properties in Phoenix with available dates and adequate space. Following a site inspection in February and a careful review of all proposals, the JW Marriott Desert Ridge was selected.

No proposal was received from Santiago for IMAST. Auckland and Sydney both had promising submissions, although the new convention center in Auckland is still under construction. Although Auckland is an appealing city and the new center will be centrally located, construction was not far enough along to make a good assessment of space. The convention center in Sydney, Australia offers good space, an excellent location with good hotel choices and restaurants within easy walking distance, and direct flight access for many people, so it was selected.

Additionally, the Board of Directors decided in June that the 2018 Annual Meeting should be moved out of Seoul, South Korea due to concerns about growing tensions and increased military activity in that area. As a result, the committee was charged with finding a new location for next year’s meeting. To avoid conflict with other meetings, such as NASS and Eurospine, that have already been scheduled for fall dates in 2018, the committee wanted to stay with the original dates of October 10-13, which made finding a venue on relatively short notice somewhat more difficult.

Requests for proposals were sent to various locations in Asia and to Bologna, Italy, which had already submitted a proposal for a future meeting. Most could not provide the desired dates, but Bologna did and was felt to be the most promising of those that were available. A site inspection in early July confirmed that Bologna could be a good option for the meeting and it was put forth as first choice. The Board of Directors approved all three selections – Phoenix, Sydney, and Bologna – at their meeting in July.

UPCOMING MEETINGS:

2018
Annual Meeting – Bologna, Italy – October 10-13
IMAST – Los Angeles, CA – July 11-14

2019
Annual Meeting – Montreal, Canada – September 18-21
IMAST – Amsterdam, Netherlands – July 17-20

2020
Annual Meeting – Phoenix, AZ – September 9-12
IMAST – Sydney, Australia – July 15-18

 

Chair: David W. Polly, Jr. Committee: Kenneth MC Cheung, Chair Elect; John P. Dormans, Past Chair; Henry F.H. Halm, IMAST; Ferran Pellisé, Global Outreach; Ronald A. Lehman, Jr., IMAST; Benny T. Dahl, WWC

IMAST Committee Update

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

We have just concluded our first Scoliosis Research Society meeting on the continent of Africa with the 24th International Meeting on Advanced Spine Techniques (IMAST) in Cape Town on July 12-15, 2017.  We had over 25% of the delegates from Africa attend this meeting, and we have already begun to plan the 25^th IMAST meeting to be held in Los Angeles, CA in July 2018.   It is hard to believe that this will be the 25^th iteration of this game changing meeting that first allowed our society to explore with more vigor the innovation and novel techniques that have significantly advanced our field over the past few decades.  With the help of Henry F. H. Halm, IMAST Co-Chairman, and SRS President Elect Todd Albert, we anticipate an outstanding venue and program.  Los Angeles has much to offer, and is located within a few hours’ drive to numerous parks, beaches, and historical sites, allowing for the entire family to enjoy this amazing area.

In conjunction with the Program Committee, the IMAST Committee reviewed over 1,506 abstracts for the recent meeting.  We selected 129 four and two minute podium presentations.  In addition, we had an exciting educational program, featuring symposia on innovative methods and safety and quality that were all 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.  Interestingly, nearly half of all abstracts were submitted from outside of North America, further enhancing this as a truly global society.

There were 17 Hands on Workshops (HOWs), and 28 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.  We also changed the sessions this year, by holding no more than three concurrent sessions.  This was to allow participants the ability to attend every symposia and instructional course lecture that they felt compelling.  We took the feedback from past years, and continue to restructure the meeting to meet the goals and suggestions of the membership.

In addition, Henry 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.  As always, the SRS and the IMAST Committee are committed to meeting the needs of our membership.

I would personally like to thank our President, Kenneth Cheung, MD and the IMAST Committee, as well as the other members of the Presidential Line for their support and guidance through this process.  As well, I would personally like to thank Henry Halm, MD for his assistance and partnership with the endeavor. We look forward to working closely with Todd Albert, MD and the committee for next year's meeting.  Also, the staff at the SRS, namely Courtney Kissinger, Ann D’Arienzo, Lily Atonio 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: Ronald A. Lehman, Jr. Co-Chair: Henry F.H. Halm Committee: David H. Clements III (CME), Andrew H. Jea, Dean Chou (C), D. Kojo Hamilton (C), Mun Keong Kwan (C), Robert Lee (C), Ibrahim A Omeis (C), Juan S Uribe (C), Jeffrey Dean Coe, Yong Hai, Hossein Mehdian, Stefan Parent

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 their own spine fellowships, multiplying the impact that these training programs have had.  The Development Committee is working to memorialize the “Genealogy” of our members.  We have begun to contact 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.  To track where fellows have gone to help other fellowships grow or start their own fellowships will help develop 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.  We are hoping to release the Founding Fellowships home page at the Annual Meeting in Philadelphia! The Genealogy page is being designed with fundraising in mind to allow SRS members, and others listed, to donate and designate their current or past fellowship affiliation. It will have functionality to allow members to view total donations from their fellowship as well as percent participation. Thanks to Josh Pahys, our Website Committee liaison, for his critical contributions to this effort!

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 this support diminishing over recent years. Thus, to continue our mission, we need to increase our donor support from our dedicated membership.

 

Chair: Serena S. Hu Committee: John R. Dimar II, Past Chair; John P. Dormans, PPII; John A.I. Ferguson; Panagiotis G. Korovessis; Steven M. Theiss; Matthew A. Halanski (C); Antony Kallur (C); Elijiro Okada (C); David W. Polly, Jr., PPI; Kamal N. Ibrahim; Paul D. Sponseller, Chair Elect; Hilali H. Noordeen; Christopher I. Shaffrey; Justin S. Smith; Alexander R. Vaccaro III; J. Abbott Byrd III, Treasurer

Global Outreach Committee Update

Ferran Pellisé, MD, PhD
Global Outreach Committee Chair

The Global Outreach Committee has worked hard to accomplish the committee charges and develop its main priorities: GOP Road-Map and new online GOP database.

Our website has been recently updated and new educational material is now available. The FOCOS Hospital halo-gravity traction (HGT) system video is now accessible online. The video is an excellent opportunity to learn how to build HGT-walker and wheelchair frames.

The new, simple, practical, and M&M compatible online GOP database has been piloted and is accessible online. This “basic” database will replace trip reports and become the prospective registry of SRS GOP activity. To submit your GOP report, please click here. To request report data, please email Lily Atonio at latonio@srs.org.

The GOP Road Map has been discussed and agreed with committee members and GOP site leaders and is now being refined. Three site categories based on infrastructure, surgical activity and reporting are considered. Educational SRS endorsement shall be increased for sites continuously accomplishing reporting duties. A positive bias for GOP associated applicants will be added when applying to awards and scholarships linked to global outreach.

At the Annual Meeting in Philadelphia the GOP Lunchtime Symposium will be entitled “SRS GOP Mission Trips – How to be Effective and Safe at a Reduced Cost”. During this Symposium you will hear from members of the GOP Committee and representatives from SRS-GOP Endorsed Sites about tips and tools that can help us all to make care effective and safe at a reduced cost in GOP Missions and Activities.

We actively seek participation of all SRS members in our outreach program. Please take a look at the new updated interactive world map including all our sites and participate in the GOP activities at the Annual Meeting to interact with site leaders and to network.

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

 

Chair: Ferran Pellisé Committee: J. Michael Wattenbarger, Chair Elect; Saumyajit Basu; Gregory M. Mundis; Phyllis d'Ambra (A); Benny T. Dahl (WWC); Raphael D. Adobor (C); Carlos A. Aguiar (C); Donald J. Blaskiewicz (C); Antonio Hurtado (C); Seung-Jae Hyun (C); Brice Ilharreborde (C); Timothy P. McHenry (C); Edward K Nomoto (C); Shoji Seki (C); Akin Ugras (C); Andrew G. King; Elias C. Papadopoulos; Edward P. Southern; Vidyadhara Srinivasa; Christopher J. Bergin; Hani H. Mhaidli; Kan Min; Dheera Ananthakrishnan, Orthopaedic Link Liaison; Bettye A. Wright (E), ex officio

Translation Committee Update

André Luís F. Andújar, MD
Translation Committee Chair

The Translation Committee is responsible for translating all Patient Education materials on the SRS website to other languages, in coordination with the Patient Education and Website Committees. This year, we added two new languages to be translated – Russian and Czech – for a total of 14 languages being translated, helping the SRS to accomplish its mission statement which is to foster the optimal care for all patients with spine deformities.

The entire Patient and Family section of the site is already translated, as well as the AIS handbook. The current task is to translate the EOS FAQs, to be finished by the Annual Meeting in September. The Policy Manual of the Committee was written this year.

We welcome new members, Martin Repko and Sergey Mlyavykh, who will be responsible for the translation into the Czech and Russian languages, respectively, as well as Dr. Tsutomu Akazawa, who is replacing Dr. Noriaki Kawakama in the Japanese language.

Thanks to all the Committee members as well as to Dr. John Dimar, MD for his mentorship this year. I would personally like to give a special thanks to Dr. Munish Gupta, MD who did an excellent job as the first Chair of the Committee, coordinating and leading all the Committee members in the first years of the Committee, inspiring us to continue our tasks.

 

Chair: André Luís F. Andújar, Portuguese Committee: Munish C. Gupta, Past Chair; Todd Milbrandt, Website Chair; Massimo Balsano, Italian; Haluk R. Berk, Turkish; Ernesto S. Bersusky, Spanish; Yonggang Zhang, Chinese; Hazem B. El Sebaie, Arabic; Tsutomu Akazawa, Japanese; Eung-Ha Kim, Korean; Avraam Ploumis, Greek; Henry F.H. Halm, German; Jean-Marc Vital, French; Martin Repko, Czech; Nosrat Javidan, Persian; Sergey Mlyavykh (C), Russian

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Research Grant Committee Update

Patrick J. Cahill, MD
Research Grant Committee Chair

The committee reviewed, evaluated, and scored 22 grant applications during the spring cycle. The committee members were divided into 6 groups based on the members’ self-ranked expertise in specific areas of knowledge. A leader was assigned to each group. Each group evaluated 7-8 grants that loosely coincided with the group’s expertise. Each member assigned a ranking from 1-5, and the grant applications rankings were assigned an average score. All grant application scores from all 6 teams were posted to all members. A conference call of the group leaders was carried out to decide the final ranking.

The committee has partnered with several outside scientists with expertise in molecular, animal, and biomechanical research to assist in evaluating grants where our member volunteers need additional expertise. The outside reviewers have participated successfully in the past two cycles.

Dr. Leah Carreon, Chair Elect, led the outcomes sub-committee. This sub-committee is tasked with evaluating the progress and success of work associated with awarded grants. The creation of the sub-committee has standardized the process of reviewing the progress of awarded grants. She and her team have made the process more consistent and transparent.

Dr. Carreon is restructuring the scoring system to make it consistent with NIH, OREF, and POSNA scales. The new system will be 1-9 with 1 representing the best possible score. Furthermore, objective criteria for awarding various scores are to be better delineated with the new system. This scale will aim to decrease variability among reviews and provide guidance for new and candidate member reviewers. The scale is targeted for a roll-out in the Fall 2018 cycle.

The committee also periodically convenes ad hoc review teams to review proposals for directed research efforts as determined by the PL.

This spring, the research grant committee awarded the following grants totaling $59,886.00:

• James Sanders – Standard Investigator – Growth of the Spine in Children- A Longitudinal, Prospective Investigation - $49,886.00
• Serkan Inceoglu – Small Exploratory – Endplate Micro-structure, Bone Quality, and Mechanical Properties: In-vitro Biomechanical Investigation towards Predicting Endplate Fractures - $10,000.000

Congratulations to these investigators.

 

Chair: Patrick J. Cahill Committee: Michael Rosner, Past Chair; Siavish S. Haghighi; James S. Harrop; Seyed Mir Mostafa Sadat; Maxwell Boakye (C); Jason PY Cheung (C); Calvin C Kuo (C); Charles Gerald T Ledonio (C); Joshua Murphy (C); Chris J. Neal (C); Saba Pasha (C); Themistocles S. Protopsaltis (C); Huiren Tao (C); Feng Zhu (C); David F. Antezana; Leah Y. Carreon, Chair Elect; Morio Matsumoto; Vikas V. Patel; Ivan Cheng; Marcel F. Dvorak; Frank LaMarca; Luis R. Munhoz da Rocha; Virginie Lafage; Jwalant S. Mehta; Robert A. Morgan; Jianxiong Shen; J. Abbott Byrd III, Treasurer Outcomes Sub-Committee: Leah Carreon, Patrick Cahill, Michael Rosner, Ivan Cheng, Virginie Lafage, Kathy Blanke

Morbidity and Mortality Committee Update

Darrell S. Hanson, MD
Morbidity and Mortality Committee Chair

The role of the Morbidity and Mortality Committee (M&M) is to continue to oversee the collection of data to assess the complication rates on a year-to-year basis, streamline the data submission process for the membership so that it is not terribly onerous, and to use the available data for presentations and publications.  Our committee continues to strive to improve the data entry site and increase the value added to the membership of the SRS.

One of the real strengths of the SRS is the enduring commitment of the membership to provide the requisite information necessary in order to maintain a robust database.  To this end, I’m happy to report that the participation of the membership contributing to the database continues to be relatively high.  We are currently in the process of analyzing the participation data for 2016.  Please remember that if a complication is entered, you must fully complete the detailed module(s) for each complication in the “add complication case” section.  There are still some cases with incomplete data fields.  Remember, our data is only as good as the information that is entered.  If you have questions about the submission process, there is a link under the Morbidity and Mortality section titled “2017 instructions” that answers most questions.

Under the main page of the data submission website, members can also access their personal yearly M&M data for the last several years.  The dashboard representation allows a comparison of the individual data to the overall SRS membership data that has been submitted.

A special member benefit of the M&M database is the opportunity to use the M&M data for research.  We have had several RFPs submitted to use the database for investigations.  We are currently working on an updated bibliography of the publications that have been the result of research conducted through the M&M database.  The process and guidelines for submitting an RFP are located in the Members-Only section of the SRS website under Morbidity and Mortality. 

I look forward to giving a more complete presentation at the Business Meeting presentation on Friday, September 8 in Philadelphia.

Finally, I would like to thank the entire committee for their tireless efforts, especially Kathy Blanke.

 

Chair: Darrell S. Hanson Committee: Jose A. Herrera-Soto, Past Chair; Kathy Blanke (A); Ian W. Nelson; Brent D. Adams (C); Paloma Bas Hermida (C); Joseph Gjolaj (C); Nanjundappa S. Harshavardhana (C); Sang D. Kim (C); Addisu Mesfin (C); Peter G. Passias (C); Nasir Ali Quarishi (C); Christopher J. Bergin; Vicki Kalen (E); Peter B. Slabaugh; Jeffery D. Thomson, Chair Elect; William Francis Lavelle; Jon Edward Oda

Coding Committee Update

Matthew D. Hepler, MD
Coding Committee Chair

Coding Posterior Interbody Fusion with Decompression
(the Byzantine world of medical coding)

One of the most frequent coding controversies over the last several years has been how to properly code a posterior interbody fusion (22630 or 22633) with a decompression (laminectomy/63047) at the same level. This is an important issue as lumbar interbody fusions and decompressions are some of the most common spine procedures performed and improper coding can lead to CMS audits. More interestingly, exploring this “coding conundrum” in detail helps unveil some of the mechanisms and entities that have come to govern the byzantine process of medical coding.

The primary codes involved include 22630, 22633, and 63047 (for simplicity sake we will not consider some of the add on codes frequently performed in these procedures). The CPT code descriptions are as follows:

22630
Arthrodesis, posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar.

22633
Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar.

63047
Laminectomy, facetectomy, and foraminotomy (unilateral or bilateral) with decompression of spinal cord, equine, and/or nerve root(s) (eg spinal or lateral recess stenosis) single vertebral segment, lumbar.

 

CPT Guidelines

One of the first distinctions to recognize is that arthrodesis codes are in the Musculoskeletal System chapter of CPT (22590-22634) and posterior decompression codes are in the Nervous System section of CPT (63001-63066). These are different organ systems and CPT has, logically, always maintained it is appropriate to include the additional code for a decompression when performed at the same level as a fusion, even though it may be through the same incision. So for example a spondylolisthesis with severe stenosis may be treated with a postero-lateral fusion (22612) and a laminectomy  (63047-51). Remember stand alone codes include the work for the 90 day global period as well as the intra operative work; modifier 51 (multiple procedures) allows additional stand alone procedures which are “discounted” to appropriately represent the additional intra operative work involved (the work RVUs for the 90 day global already accounted for by the first, highest RVU valued primary code).

This is simple enough in the above example when the primary procedures involve distinctly different organ systems. The posterior interbody codes (22630 and 22633) are more complicated because they require some degree of decompression/laminectomy to perform the interbody fusion even though the original vignette used to create the code was for a revision fusion procedure with minimal signs of nerve root dysfunction. Attempts were made to clarify this distinction early on with the CPT editorial change: “laminectomy and/or discectomy sufficient to prepare the interspace (other than for decompression).

So for example a patient undergoing a posterior interbody fusion with leg pain due to lateral recess stenosis/HNP would not justify the additional laminectomy code since the work involved in removing portions of the lamina, facet and disc are included in the interbody procedure. This is also the case when the stenosis is contralateral to a single sided TLIF approach since the vignette for the posterior interbody codes includes a bilateral approach (the vignette is the specific clinical scenario used to create a new code).

However, CPT guidelines clearly state that additional decompression beyond the necessary laminectomy, facetectomy, or discectomy to access the interspace may be separately reported. So for example a patient undergoing an interbody fusion with severe canal and/or foraminal stenosis who requires a complete laminectomy for decompression beyond what is necessary to prepare the interbody space for fusion would report 22630/22633 with 63047. This might include modifier 51 multiple procedures or modifier 59, distinct procedural service (more on this later).  You must, of course, provide adequate documentation in the operative report supporting the need for and performance of any such distinct or additional procedures.

 

Medicare Guidelines (the Byzantine twist)

Although CPT guidelines clearly state that additional decompression beyond that necessary to prepare the disc space may be reported separately (and many payors follow these CPT rules), CMS has disregarded them and prohibited payment for 63047 with 22630/22633 at the same level since 2015.  To understand how we arrived at this conflicting set of guidelines we have to examine how CMS adopted the use of CPT codes (which are owned and maintained by the AMA) while developing its own software (NCCI) to regulate their use (see Modifer 59 SRS newsletter August 2016).

NCCI (National Correct Coding Initiative), CMS’s national editing software system, was developed in the 1990s to detect and prevent “unbundling (billing multiple procedure codes when one code is more appropriate). These NCCI edits apply only to services that are performed on the same day, for the same patient, and billed by the same physician. These edits identify an exhaustive list of code pair combinations that generally should not be reported together by a provider on the same day of service. They further specify combinations which should: never be reported together (0), that may be reported together in special circumstances with an appropriate modifier (1), or are mutually exclusive (ME). In 1999 the NCCI Policy Manual for Medicare Services implemented edits for code pairs 22630 and 63047, which were updated in 2012 to include 22633 and 63047 and again in 2015. The January 2015 NCCI edit guideline states:

“CMS payment policy does not allow separate payment for CPT codes 63042 (laminotomy...; lumbar) or 63047 (laminectomy...; lumbar) with CPT codes 22630 or 22633 (arthrodesis; lumbar) when performed at the same interspace. If the two procedures are performed at different interspaces, the two codes of an edit pair may be reported with modifier 59 appended to CPT code 63042 or 63047.”

Multiple efforts were made by various spine group coding organizations to resolve the conflict between the CPT and CMS/NCCI guidelines but CMS has elected not to overturn the edit.

More recently, the October 2016 CPT assistant article stated CPT codes 63047 and 22633 may not be reported together at the same interspace. NASS, CNS, AANS, and ISASS wrote an erratum which AMA has denied and efforts to appeal have been unsuccessful to date as there in no appeal process.

 

In Summary

As noted previously CMS guidelines are in direct conflict with CPT guidelines regarding the combination of posterior interbody fusion with decompression at the same level. As a result coding these procedures has been dependent on the guidelines of the specific payer.

For Medicare/Medicaid (CMS) you may code for 22630/22633 with 63047 to document the work performed. CMS will not pay for the decompression (63047) for the reasons explained and this denial should not be repealed. Also, CMS guidelines indicate you should not append a modifier to this coding combination.

Payers that follow CPT guidelines have permirred a laminectomy at the same level as a posterior interbody fusion with appropriate documentation. In these cases it was appropriate to append modifier 59 to indicate a distinct organ system or modifier 51, multiple procedures according to each payers recommendation. More recently, CPT assistant publication states decompression cannot be reported with interbody fusion at the same level; therefore anticipate payers will begin to deny this as well.

 

Reference:

Laminectomy and Interbody Fusion Confusion.
John Kevin Ratliff, MD, FAANS | Departments | Coding Clarity
AANS Neurosurgeon: Volume 25, Number 1, 2016

Spine Surgery Quandary: Posterior Lumbar Interbody Fusion
When do you bill 63056-59 with 22633, rather than 63047-59?
By Kim Pollock, RN, MBA, CPC, CMDP
AAPC Spine Surgery, June 2016

A Timeline of Posterior Lumbar Interbody Fusion and Decompression of Nerve Roots: Can Posterior Lumbar Interbody Fusion and Decompression Be Reported Together at the Same Interspace?
R. Dale Blasier, MD, Christopher Kauffman, MD, Paul Saiz, MD, NASS Coding Committee
NASS Spineline, April 2016

To access past Coding Corner articles in our Members' Only section of the website, please click here.

 

Chair: Matthew D. Hepler Committee: Shay Bass; Jahangir K. Asghar (C); Judson W. Karlen (C); Barton L. Sachs, Chair Elect; Michael S. Chang; Walaa Elassuity; R. Dale Blasier, Advisory; Richard J. Haynes, Advisory