President’s Message

SRS continues to be very busy.  We have just finished abstract submissions and had 1,541 successful submissions; one of the largest within the past years. Thank you to everyone who submitted research; it is what makes our IMAST and Annual Meeting & Course superb. The Program Committee, led by Justin Smith, MD, PhD and the IMAST Committee, led by Ronald Lehman, MD and Henry Halm, MD met the first week of March, in Orlando, for the abstract selection meeting. At this meeting, they went through the challenging selection process of finalizing the abstracts for both programs. The Education Committee, led by Theodore Choma, MD, is in the midst of their process to put together the best program possible for the Pre-Meeting Course, Half-Day Courses and the Lunchtime Symposia for the Annual Meeting.

President Elect Kenneth MC Cheung, MD led a retreat at the American Academy of Orthopaedic Surgeons (AAOS) meeting in Orlando to look at our educational offerings. What we are currently doing is excellent. Prof. Cheung is focused on how we can improve the continuity of our education and if we need to have a more basic approach for some of our Courses. This meeting involved many members, providing us a global perspective.

Michael “Tim” Hresko, MD and many others have gone through the arduous process of getting our early detection message through to the United States Preventive Services Task Force (USPSTF) which is now reconsidering their recommendation against screening for scoliosis. Dr. Hresko and others have led the way to get endorsements from the Pediatric Orthopaedic Society of North America, the American Academy of Orthopaedic Surgeons and the American Academy of Pediatrics. This effort has been made possible by the generation of high quality evidence from the BrAIST trial led by Stuart Weinstein, MD and Lori Dolan, PhD.  Thank you to all involved.

The risk stratification effort led by Steve D. Glassman, MD and Frank Schwab, MD, and significantly assisted by many others, is picking up steam. This effort is a multi-pronged approach involving the American College of Surgeons National Quality Improvement Program (NSQIP), the Scandinavian spine registries and established study group data bases (such as HSSG, GSSG, CWSSG, ISSG, ESSG). As a Society, we have made a very considered decision to invest in intellectual insights as well as financial support toward this effort. I look forward to this endeavor improving our ability to do patient specific risk stratification so that we and our patients can do a better job of selecting who will and who will not benefit from our significant spinal interventions.

The Research Committee, led by Michael Rosner, MD, has made its selections for the Fall funding cycle and the deadline for the Spring funding cycle is rapidly approaching. We are always looking for high quality grant applications. Please keep them coming.

SRS has successfully led two more installment of Spine Deformity Solutions: A Hand-On Course. The first international program was held in October 2015 and was chaired by Ahmet Alanay, MD and Munish Gupta, MD in Istanbul, Turkey. This course was a tremendous success, hosting 40 participants from 23 countries along with an outstanding faculty of SRS members. This past February, SRS hosted the 6^th Spine Deformity Solutions in conjunction with AANS in Las Vegas, NV. The course was chaired by Christopher P. Ames, MD and Munish Gupta, MD, and received excellent reviews from the attendees. These courses continue to be an intensive effort that provides exceptional education for those who attend.

Hopefully you are taking advantage of the new website. Many thanks to Ron El-Hawary, MD his committee, and the SRS staff who have all put in countless hours improving our website. Your suggestions, comments and contributions will continue to improve our site.

The Awards and Scholarship committee, led by Ian J. Harding, BA, FRCS (Orth), continues to be very active in selecting the Lifetime Achievement Awards, Blount Humanitarian Award, the next group of traveling fellows and the many, many scholarship recipients to attend various SRS meetings and gain educational experiences with SRS fellows.

The Global Outreach Program committee, led by Ferran Pellise, MD, PhD continues their very, very active pace. All SRS members that I have personally spoken to, describe their first global outreach medical trip as being life-changing for them as well as for the patients that they are able to help. This outreach activity is continuing to expand in terms of number of sites and number of patients reached. Hopefully we will enable these sites to be able to do this work independently and then we will have truly succeeded in our mission. This committee also has the greatest challenge in scheduling conference calls as it seems it is always after midnight and before four am for someone on the call! The dedication to do this is extraordinary. Thank you.

I continue to be amazed by the time and effort put in by members of SRS to complete all of the work we are doing around the world. The dedication of all to fostering the optimal care of all patients with spinal deformity is what truly makes our Society great. Thank you and keep it going!

Sincerely,

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

Hot Topics Articles

• Historical Committee Update
• Ethics Corner
• Safety and Value Committee Update

In Memoriam

Anthony J. Bianco, Jr., MD
1926 –2016

Anthony Bianco, Jr., MD was born and raised in Duluth, Minnesota. He received his medical degree, MD, from the University of Minnesota in 1948. Following graduation, he interned at Duluth’s St. Mary’s Hospital, but was called to active duty in the U.S. Navy with the rank of lieutenant in 1949. Demobilized in late 1950, Dr. Bianco returned to Duluth to join his father in family practice.

In 1952, Bianco entered orthopedic residency at the Mayo Clinic in Rochester, Minnesota. His residency was interrupted when he was recalled to active duty during the Korean War. He served more than two years as medical officer on board the U.S.S. Banfield, an attack transport. After discharge Bianco returned to complete his residency, receiving his Master of Science in Orthopaedic Surgery in 1958, the same year he joined the Mayo orthopaedic staff.

In 1967, Dr. Bianco petitioned the orthopaedic department to allow him to limit his practice solely to children, four years before there was a pediatric orthopaedic society. Thus, he became one of the first in the nation to practice solely pediatric orthopaedics at a multispecialty academic institution. He was a Founding Fellow of the Scoliosis Research Society (1966) and of the Pediatric Orthopaedic Society (1971).

Dr. Bianco’s passion was patient care. He was a prolific and proficient surgeon, performing thousands of operations to alleviate spine curvature, congenitally dislocated hips, club feet, and other orthopedic conditions of children and adolescents. His management of both patients and parents was impeccable and marked by compassion. He was something of a legend among nurses at Rochester’s St. Mary’s Hospital for the respect and consideration he invariably showed them, even when a surgery or post-operative recovery did not go entirely as planned.

Highly respected by fellow Mayo Consultants, Dr. Bianco was elected to two terms on Mayo’s highest councils: the Board of Governors and Board of Trustees (1975-1983), served as section head of Pediatric Orthopaedics (1967-1982) and chaired the Department of Orthopaedics (1982-1988). He retired in 1991.

Dr. Bianco was well-known for his lively good humor and voracious intellectual curiosity. He seemed to know something about everything, and a lot about a lot of things. Many people sought his advice, for he was a man of solid judgement and great discretion.

For many years Dr. and Mrs. Bianco lived in the country, near Mayowood, where he bred Arabian and thoroughbred horses, and raised mastiff canines. He is survived by his wife, seven children, and nine grandchildren. He was a gentleman of the old school, and will be sorely missed and fondly remembered by all who knew him. Anthony Bianco, Jr., MD died January 3, 2016, at age 89.

Written by: Hamlet A. Peterson, MD

Pat on the Back

The Communications Committee would like to highlight the accomplishments of SRS members in the newsletter. We invite all SRS members to submit details (with photos if applicable) of your honors, awards, special activities or other efforts in which you have been involved in, to [email protected].

Historical Committee Update

George H. Thompson, MD
SRS Historian

2015 ended with the wonderful celebration of the Scoliosis Research Society’s 50^th Annual Meeting & Course, September 30 – October 3 in Minneapolis, MN.  During the meeting, there were several major events organized by the Historical Committee.  Most notably, the 50^th Anniversary Museum and the Living Legends sessions. These were the culmination of several years of planning. We owe our Past-Historian, Behrooz A. Akbarnia, MD a special debt of gratitude for his vision, leadership and hard work in bringing this to fruition. The Historical Committee had its first conference call on Tuesday, January 26, 2016. The following issues were discussed:

1. 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. It will be the main task of the Historical Committee over the next few years to add to this timeline so that we have a complete history of spine deformity.

2. A major task of the Committee, and particularly myself, will be to bring our video archives up to date. At the Annual Meeting in Prague several interviews of past SRS presidents and European greats in spine deformity will be conducted. It has been mentioned that interviews are usually conducted five years after being Past-President or a Lifetime Achievement Award winner. Changing this is to one or two years may allow more interesting interviews as important issues that shaped the presidency or a Lifetime Award Winners life will be more current and pertinent to the viewer.

3. On a sad note, we lost another SRS founding member in January of this year. Dr. Anthony Bianco of Rochester, MN died on January 3, 2016. He was 89 years old. His full obituary is listed in this issue of the newsletter.

4. Finally, in early March, Ashtin Neuschaefer, Dr. Akbarnia and I will be meeting at the SRS office in Milwaukee to review many of the documents held there and determine what should be sent to the SRS Archives at Kansas University in Kansas City. Immediately following our visit to the SRS Office, we will be traveling to the SRS Archives to review what is currently being stored at that location.

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

Research Grant Committee Update

Michael K. Rosner, MD
Research Grant Committee Chair

Research and Education remains the principle lifeline of our Society. The Research Grant Committee received a record number of grant applications in the fall cycle (October 1, 2015). Thirty-five grant applications were reviewed and considered for funding. The research committee consists of 26 members who each reviewed approximately 10-11 grants for a designated team. The 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 fall the Research Grant Committee awarded the following grants totaling $149,345.00:

The new application cycle has opened on February 1, 2016 with a deadline of April 1, 2016.

The Outcomes Subcommittee has been following the outcomes and progress reports of prior recipients and has made recommendations for distribution of the remaining funds and for those that will be invited to report at the Annual Meeting & Course in a Lunchtime Symposium. Additionally, a simple reporting mechanism is now developed to track what happens to grantees after project completion with the goal of finding out who gets published and additional funding. 

The Research Committee has been charged to focus on the following areas:

1. Evidence Based Medicine
2. Idiopathic scoliosis
3. Etiology
4. Non-op and operative treatment
5. 3D deformity of the spine and thorax
6. Adult deformity
7. Treatment and outcomes
8. Osteoporosis
   1. Osteoporotic spine fractures
   2. how it impacts scoliosis kyphosis management
   3. how it relates to spinal deformity and instrumentation
9. Early onset scoliosis treatment
10. Sagittal imbalance
11. Congenital scoliosis
12. Neuromuscular spinal deformity
13. Deformity and reconstruction arising from spine and sacral tumor treatment
14. Thoracic insufficiency children associated with spinal deformity
15. Pulmonary outcomes following common natural history of spine deformity and treatment history.
16. Risk Stratification  (Special consideration is provided for any research focusing on this topic)
17. Long-term outcomes and/or patient-generated indices/outcomes
18. Fusionless options

The Research Committee considers the following “essentials” to receive a favorable review for funding:

• 1-2 aim focus to be completed in reasonable timeframe.
• New investigator submission who has not been previously awarded funding from a major funding organization.
• Co-investigators with a proven track record
• Original science always a priority
• Multicenter approach to increase data size

The Research Committee considers the following “red flags” to receive an unfavorable review for funding:

• Salary support for clinicians
• Travel support request in grant submissions
• Requests to support/divert funds for overhead expenses
• Poor track record
• Inadequate research infrastructure
• No pilot data or prior work in the area
• Non answerable hypothesis

Ethics Corner

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

Dear SRS members,

The Ethics and Professionalism Committee will continue to publish potential ethical problems and conflicts in the newsletter and ask for the members’ input. Therefore, the Committee encourages members to submit to the committee any ethical conflicts they may face for further discussion. The following potential ethical conflict is submitted by John Lubicky, MD. Although it is a knee problem, the issue can apply to spine physical therapy (PT) care.

Is this an ethical issue?

Parents who have children that have even mild M-S injuries or who have relatively simple surgery seem to believe that formal physical therapy will be needed. It’s almost an obsession. In all honesty, most of these kids can do simple exercises taught us and supervised by the parents. But those who are sent to formal  therapy, once in the hands of some PT’s, begin a seemingly endless plan of care that seems unreasonable and unnecessary. Consider the following scenario.

A normal 14 y/o girl with recurrent patellar subluxations undergoes a double bundle MPFL reconstruction. The surgery is uneventful and her operated knee is placed in full extension in a knee immobilizer for three weeks. On exam in the office, the wounds are healed, there have been no complications and the girl is having no pain. Her knee is a bit stiff so a prescription for PT is written indicating she should have PT two times per week for four weeks. A few days later the PT sends his own prescription outlining the plan of care for physician approval. Four weeks after the first post-op visit the girl returns, walking normally, with normal ROM of the knee and no obvious quad atrophy. The girl says her knee feels fine,  she tells me the PT wants to continue therapy and sends along a request to extend the program for an additional eight weeks. The request was denied and the patient was told to discontinue formal PT. The PT sent an unhappy response to the denial. This is not an isolated example of this kind of PT directed care whether it involves extremity or spine surgery or injuries.

There may be an ethical issue for the PT as extending therapy is clearly a conflict of interest. Continuing the therapy visits is in the best interest of the PT. In some cases, the PT will insist on continued care until all the insurance coverage is exhausted. Shouldn’t we as physicians determine the need for therapy or should we allow the PT’s free reign? Since many PT’s now hold the title of DPT, it may become more difficult to deal with this issue.

Please send your opinion to [email protected]. The committee will review all responses and publish their summary in next newsletter in June 2016.

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    

Long Range Planning Committee Update

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

The Long Range Planning Committee has been tasked to pick both the 2019 and 2020 Annual Meeting & Course and IMAST venue locations. As per the international vs. North American rotation of meeting sites, the 2019 Annual Meeting will be located in North America, and 2019 IMAST will be located internationally.

After reviewing all 2019 Annual Meeting proposals and completing site visits to the top locations, the Long Range Planning Committee strongly recommended Montréal, Canada and the recommendation was approved by the Board at their recent meeting. The 2019 Annual Meeting & Course will tentatively be held September 18-21, 2019.

The Palais des Congrés de Montréal (convention center) is very well located in central Montréal, just a few blocks from the old city and with many restaurants and attractions within easy walking distance. Space is very good, with room for growth and options for program changes (such as more or fewer breakouts, Half-Day Courses, etc.). There are a number of hotels at various levels within five blocks of the center. Most of those hotels are offering complimentary internet in guestrooms, some complimentary upgrades and standard 1 complimentary room night for every 40 used by SRS. 2019 rates offered range from $166 (Dauphin) to $226 (InterContinental) for single rooms in US dollars at the current exchange rate.

The Palais des Congrés is offering a 50 percent discount on their normal rental charges. Tourisme Montréal will pay the remaining 50 percent, so the convention center will be free of charge to SRS. Tourisme Montréal will also contribute $10 CAD per room, per night to a maximum of $26,050 CAD to the SRS.

Montreal has an excellent, state of the art airport with direct flights from 23 US cities and many international cities, including Amsterdam, Athens, Barcelona, Beijing, Brussels, Dublin, Frankfurt, Geneva, Istanbul, London, Madrid, Munich, Paris, Rome, Venice and Zurich. Depending on traffic, the venue is approximately 20-25 minutes by taxi from the airport and costs approximately $40 CAD.

There are a number of good options for the Leadership Dinner and Friday reception. Dr. Dormans and Ms. Goulding visited a few of the options, most of which were felt to be good, and almost all are within a 20 minute drive of the convention center and hotels.

Montreal is a very attractive city, with excellent restaurants, hotels and attractions and very good air access. The convention center is well designed, well located and attractive. Participants would have easy access to hotels, the meeting and Montreal attractions. With the support package offered by the convention center and Tourisme Montreal, the financial aspect is outstanding. We highly recommend Montreal for the 2019 Annual Meeting & Course.

Dr. Dormans and Ms. Goulding will soon be completing site visits to Amsterdam, Netherlands, Hamburg, Germany and Birmingham, England to look at potential 2019 or 2020 IMAST locations.

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

Risk Stratification Task Force Update

Steven D. Glassman, MD
Directed Research Task Force Chair

What is Risk Stratification?

Risk stratification is the use of evidence to assist in predicting unfavorable outcome and complications.  In essence, it is an effort to quantify the evaluation process that surgeon’s undertake every time they look at a patient and recommend surgical treatment. Where risk stratification has been done most effectively, whether in healthcare or elsewhere, the common thread is adequate reliable data.  As an example, the American College of Surgeons (ACS) has built an online risk calculator through the NSQIP database, which includes granular data on over a million patients. 

Why should the SRS pursue Risk Stratification?

Spinal deformity surgery is complex and often represents a high risk/high reward proposition.  Despite our perception that spine deformity surgery is unique in terms of both patient characteristics and surgical intensity, there is limited data validating which exact aspects drive risk.  Quantifying predictors of complications and outcomes may facilitate better surgical decision making.  This may also help level the playing field as surgeons are graded based upon surgical outcomes or complications.  Certainly, one could not expect equivalent results in the treatment of neuromuscular scoliosis versus adolescent idiopathic scoliosis or young adults with coronal deformities compared to elderly patients with substantial sagittal plane deformity.

How is the SRS supporting this effort?

The SRS recognizes the importance of risk stratification from both a patient care and an access to care standpoint.  Our goal is firstly to educate the membership regarding the rationale, methodology and impact of risk stratification efforts.  At the same time, the SRS is actively supporting a broad research strategy examining risk stratification for spinal deformity.  One element is a SRS directed project building a modified consensus model to identify critical components for subsequent risk stratification processes.  In addition, the SRS has provided the Research Grant Committee with $150,000 additional funding for meritorious submissions related to the overall risk stratification research effort.  We strongly encourage SRS members with research interests in the area of risk stratification to pursue this funding opportunity. 

Coding Corner: Are Current Spinal Fusion Hospital Payment Diagnosis Related Groups (DRGS) Adequate?

S. Samuel Bederman, MD, PhD, FRCSC and David J. Wright M.Sc.

The SRS Coding Committee, with permission from the Presidential Line, agreed to support an investigation into variation in hospital costs within spinal fusion payment groups to determine whether hospitals are bearing undue financial burden, thus disincentivizing surgeons from performing these important procedures. We report our initial findings from this study.

As rates of spinal surgery have increased, hospital costs have more than tripled, resulting in a significant impact on total U.S. healthcare costs.^1–6  Hospital reimbursement from Medicare and other payers to hospitals is provided as a fixed payment for each admission by assigning patients to a Diagnosis Related Group (DRG). Patients are assigned to DRGs according to the principal procedure performed as well as comorbidities or complications managed during the admission.^7,8 This system assumes that procedures and patients can be grouped into relatively homogenous units of resource use such that a single payment will adequately cover the costs of hospitalization for most patients within a given DRG.⁸ However, several factors, including procedural complexity and unique patient characteristics, may contribute to variation within DRGs that lead to differences between hospital costs and payments. Predictable financial losses to hospitals may result in disincentives for the provision of care, potentially leading to disparities in access for some patients by limiting our ability to treat these patients.

Prior work in total hip arthroplasty (THA) revealed that procedural differences, such as those between primary and revision THA, were one source of variation not adequately accounted for in existing DRGs.⁹ Mean hospital cost, operative time, estimated blood loss, and length of stay were found to be significantly higher for revision THA than for primary THA, even though both procedures were reimbursed equally under a single DRG (DRG 209).⁹ The cost variation within this DRG, explained largely by procedural differences between primary and revision THA, raised concern for patient access to care as hospitals were deterred from performing revision procedures in an attempt to limit ongoing financial losses.¹⁰ Following this study, the Centers for Medicare and Medicaid Services (CMS) effectively “split” this DRG into separate “primary” and “revision” DRGs in an effort to create more homogenous payment groups with more equitable reimbursement. In doing so, the CMS established an effective benchmark for excessive within-DRG cost variation.^11,12

A recent study simulating bundled payments in spine surgery suggested that wide cost variation may also exist within current spinal fusion DRGs.¹³ However, no study has examined current spinal fusion DRGs to determine the magnitude of cost variation within each group. As in total joint arthroplasty (TJA), wide cost variation within spinal fusion DRGs, if present, may lead to discrepancies between hospital costs and payments, placing undue financial burden on some hospitals and potentially compromising access to care for certain patients.

We investigated cost variation within spinal fusion DRGs with a retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) for 2011 which contained over 8 million inpatient admissions from 1,049 hospitals.¹⁴

 Patients were grouped according to 2011 CMS Medicare Severity-Diagnosis Related Groups (MS-DRGs) and included all patients assigned to spinal fusion DRGs 453 to 460 and TJA DRGs 466 to 470 (Table 1). An aggregate of TJA DRGs 466 through 470 were used to re-create “DRG 209,” which served as a benchmark for cost variation in this study.  We measured variation using the coefficient of variation (CV), defined as the ratio of the standard deviation (SD) to the mean (CV=SD/mean x 100), for all direct hospital costs within each DRG.^15–17

Table 1. Medical Severity-Diagnosis Related Groups included in this study.

† DRG 209 only existed prior to 2004. For this study, DRG 209 was reconstructed by combining all current TJA DRGs back into one DRG. APF = “anterior/posterior fusion” (combined anterior/posterior spinal fusion). CF = “complex fusion” (spinal fusion except cervical with spinal curvature, malignancy, infection or 9+ fusion levels). SF = “spinal fusion” (spinal fusion except cervical). MCC = Major Complication or Comorbidity. CC = Complication or Comorbidity.

Variation (measured by CV) in cost within spinal fusion DRGs ranged from 44.2 for DRG 460 (Simple Fusion) to 52.6 for DRG 456 (Complex Fusion with Major Comorbidity/Complication). The benchmark group, DRG 209 (TJA2005), had a CV of only 38.2. When compared to this benchmark, all spinal fusion DRGs had significantly higher CVs (p-values < 0.0001).   The mean costs for spinal fusion DRGs ranged from $27,153 for DRG 460 to $77,965 for DRG 456 while the estimated cost for TJA DRG 209 was only $15,903.  In general, the cost variation as well as costs increased with increasing procedural and patient complexity (Figure 1).

Figure 1. CVs for DRGs grouped by procedural category and medical severity.


DRGs grouped by procedural category (x-axis) and medical severity (z-axis). CV is plotted on the y-axis. The control TJA DRG is highlighted in blue. CF = “complex fusion” (spinal fusion except cervical with spinal curvature, malignancy, infection or 9+ fusion levels). SF = “spinal fusion” (spinal fusion except cervical). MCC = Major Complication or Comorbidity. CC = Complication or Comorbidity. Without = without MCC or CC. Note that SF does not have a “CC” DRG in the 2011 MS-DRG coding.

As in TJA, procedural factors such as surgical approach, invasiveness, and complexity are sources of cost variation within spinal fusion DRGs that may serve as potential targets for coding changes that could be implemented to further homogenize spinal fusion payment groups. While it could be argued that procedural factors are already accounted for by procedural categories in current spinal fusion DRGs, this study demonstrates that current categories do not, in fact, define homogenous units of resource use, suggesting that reevaluation is warranted.

To further illustrate why there may be significant variation in current DRGs, consider a “standard fusion” (spinal fusion except cervical) procedural category (DRGs 459 and 460). This category makes no distinction between an eight-level fusion and a one-level fusion as long as both procedures are performed from a single (e.g. posterior) approach and do not involve curvatures, malignancies, or infections. Furthermore, even seemingly common procedures such as a single level fusion can have a wide range of outcomes based on procedural factors that are not captured in current DRGs. For example, in a study of patients undergoing one-level or two-level transforaminal lumbar interbody fusion (TLIF), hospital length of stay varied from 3 days for patients who received a minimally invasive TLIF to 4.2 days for those who received a traditional open TLIF.¹⁸ The increased length of stay associated with a traditional open TLIF might significantly increase total hospital costs. However, the current DRGs for single-level posterior fusion (DRG 459 or 460) make no distinction between these surgical approaches. Unlike TJA DRG 209, which could be re-categorized into separate DRGs based on clearly defined “primary” and “revision” procedural factors, it may not be feasible to categorize spinal fusion DRGs in a similar fashion given the multitude of different procedures utilized. Rather, it may be more appropriate to explore other procedural measures, such as the degree of surgical invasiveness, to more accurately define homogenous payment groups.¹⁹

In summary, this preliminary analysis demonstrates that current cost variation within spinal fusion DRGs is excessively high. Both patient medical severity (complications and comorbidities) and procedural factors (approach, invasiveness, complexity) appear to contribute to the high degree of cost variation within groups. As previously demonstrated in TJA aggregate DRG 209, this variation may be leading to differences between hospital costs and payments that places undue burden on some hospitals and potentially compromises access to care for patients.¹⁰ This study highlights the need for future work to identify potential changes in coding for current spinal fusion payment groups. By grouping patients into more homogenous units of resource use, a single fixed payment would more adequately cover the costs of hospitalization for patients within each group. In an atmosphere of healthcare reimbursement that is rapidly moving towards episode-based bundled payments, such efforts to homogenize payment groups will ensure equitable hospital reimbursement and improved patient access to care.

References

1.        Rajaee, S. S., Bae, H. W., Kanim, L. E. a & Delamarter, R. B. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Spine (Phila. Pa. 1976). 37, 67–76 (2012).

2.        Baaj, A. A., Downes, K., Vaccaro, A. R., Uribe, J. S. & Vale, F. L. Trends in the treatment of lumbar spine fractures in the United States: a socioeconomics perspective. Journal of Neurosurgery: Spine 15, 367–370 (2011).

3.        Weinstein, J. N., Lurie, J. D., Olson, P. R., Bronner, K. K. & Fisher, E. S. United States’ trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila. Pa. 1976). 31, 2707–2714 (2006).

4.        Deyo, R. A. et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 303, 1259–1265 (2010).

5.        Cowan, J. A. et al. Changes in the utilization of spinal fusion in the United States. Neurosurgery 59, 15–20; discussion 15–20 (2006).

6.        Cherkin, D. C., Deyo, R. A., Loeser, J. D., Bush, T. & Waddell, G. An international comparison of back surgery rates. Spine (Phila. Pa. 1976). 19, 1201–1206 (1994).

7.        Centers for Medicare and Medicaid Services. Acute Inpatient PPS. (2014). at

8.        Hsiao, W. C., Sapolsky, H. M., Dunn, D. L. & Weiner, S. L. Lessons of the New Jersey DRG payment system. Health Aff. (Millwood). 5, 32–45 (1986).

9.        Bozic, K. J. et al. Hospital resource utilization for primary and revision total hip arthroplasty. J. Bone Joint Surg. Am. 87, 570–576 (2005).

10.      Barrack, R. L. The evolving cost spectrum of revision hip arthroplasty. Orthopedics 22, 865–6 (1999).

11.      Bozic, K. J. CMS changes ICD-9 and DRG codes for revision TJA. AAOS Bulletin (2005). at

12.      Centers for Medicare and Medicaid Services. Medicare Program; Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates. Federal Register Vol. 70, No. 155 47303–47305 (2005). at

13.      Ugiliweneza, B. et al. Spinal surgery: variations in health care costs and implications for episode-based bundled payments. Spine (Phila. Pa. 1976). 39, 1235–42 (2014).

14.      Healthcare Cost and Utilization Project (HCUP). Overview of the National (Nationwide) Inpatient Sample (NIS). Agency for Healthcare Research and Quality (2015). at

15.      Reed, G. F., Lynn, F. & Meade, B. D. Use of coefficient of variation in assessing variability of quantitative assays. Clin. Diagn. Lab. Immunol. 9, 1235–9 (2002).

16.      Pope, G. C., Welch, W. P., Zuckerman, S. & Henderson, M. G. Cost of practice and geographic variation in Medicare fees. Health Aff. 8, 117–128 (1989).

17.      Luft, H. S. Economic incentives to promote innovation in healthcare delivery. Clin. Orthop. Relat. Res. 467, 2497–505 (2009).

18.      Villavicencio, A. T., Burneikiene, S., Roeca, C. M., Nelson, E. L. & Mason, A. Minimally invasive versus open transforaminal lumbar interbody fusion. Surg. Neurol. Int. 1, 12 (2010).

19.      Mirza, S. K. et al. Development of an index to characterize the ‘invasiveness’ of spine surgery: validation by comparison to blood loss and operative time. Spine (Phila. Pa. 1976). 33, 2651–2661; discussion 2662 (2008).

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

Website Committee Update

Ron El-Hawary, MD, MSc, FRCS(C)
Website Committee Chair

The new SRS website was launched in September 2015 in conjunction with the 50^th Anniversary Meeting of our Society.  Overall, this tremendous undertaking was a very positive experience and I would like to thank the Website Task Force, .orgSource, EDI, and SRS Staff (in particular Shahree Douglas and Ann Shay).  As well, we certainly appreciate the guidance and support from the SRS Board, including John Dormans, MD and Daniel Sucato, MD, MS to ensure that a high quality website could be achieved. 

Features of the new website include a new home page design based on three clearly defined entry points, easy to use drop-down mega-menus for each audience and new “landing pages” throughout the site, significant enhancements to the Patient and Family section with a new sub-audience focus and new content, simplification of problem areas such as dense text and multiple overlapping Q&A pages, focus on user friendly language and ways of presenting content, increased use of graphics and pictures and user friendly design for mobile use.  Initial reviews of the website have been positive and we plan to re-examine website usage this fall via Google Analytics in order to quantify the impact of the new website.

Although the Website Committee is excited about the launch of our new website, we realize that there is still plenty of work to be done.  Currently, EDI is helping convert PDF's to more mobile friendly .HTML files.  Shahree Douglas is working with SRS Staff to help prioritize these efforts.  Based on last year's work by over 30 SRS member volunteers, we are in the midst of updating the content on the website.  Areas under active update currently involve the following:  Non-operative, Coding, Awards, Global Outreach, Development and Advocacy.

Our group is interested in exploring social media and feel that we should initially focus efforts on Facebook parent education material.  We are working on identifying the resources necessary to do this well and are creating a mini-task force to help create a strategic plan for the content on Facebook and answering patient inquires.

Another new initiative that we support for our website is an Early Onset Scoliosis educational video and illustrations.  We are looking at the development of professional grade media content, specifically an animated video and illustrations, for the purpose of educating parents and patients diagnosed with early onset scoliosis.  This will be a combined venture with Growing Spine Foundation, Children's Spine Foundation and POSNA.   In addition, the SRS Growing Spine Committee is interested in developing an EOS Casting webinar and our committee is helping to explore this potential, including vendors and long term storage of these webinars on our site.

We will be developing educational videos for the patients/families section of website.  We plan to have surgeon interviews/Q&As recorded and added to the site.  Our committee will help create/write scripts to address patients' most frequent questions and concerns.  The goal will be to film these videos during the SRS Annual Meeting and to place them on the website by Fall 2016.

Other possible future directions, as proposed by members of our committee include, exploring potential collaborations with insightmedi.com (secure photo sharing network for healthcare professionals) and with touchsurgery.com (virtual surgical simulation website); updating website photos; increasing dynamic content on the website and creating educational pages/games for young children with scoliosis.  Our committee looks forward to working with all SRS members this year to ensure that our website maintains its new, vibrant look and feel with relevant and updated content.  Please do not hesitate to contact me if you have comments or suggestions for our website.

Chair: Ron El-Hawary, MD Committee: Anthony S. Rinella, MD; George H. Thompson, MD; Jonathan H. Phillips, MD; Theodore T. Choma, MD; Lawrence L. Haber, MD; John C. France, MD; Munish C. Gupta, MD; Todd Milbrandt, MD; Jahangir K. Asghar, MD; Chee Kidd Chiu, MBBS MSOrth; Michael P. Kelly, MD; Toshiaki Kotani, MD, PhD; Roger K. Owens, MD; Denis Sakai, MD; Michael S. Roh, MD; Anthony A. Scaduto, MD; Timothy R. Kuklo, MD, JD; Ahmad Nassr, MD; Peter D. Angevine, MD, MPH; Lloyd A. Hey, MD, MS

Safety and Value Committee Update

Suken A. Shah, MD
Safety and Value Committee Chair

The Safety and Value Committee continues to work on ways to bring safety and value initiatives to our membership and keep folks aware of developments in this constantly changing landscape.  In order to make spinal deformity surgery sustainable, we need to demonstrate that what we do improves quality of life and can be done reproducibly, safely and cost-effectively. 

We have submitted applications for educational sessions during the 51^st Annual Meeting & Course dealing with value initiatives, the era of bundled care in spine surgery, best practice guidelines for adult and pediatric deformity, reducing variability and eliminating error.  We are working closely with the Risk Stratification Task Force to bring critical issues to the forefront and support their education and research initiatives.  There is work being done to develop a surgical risk score.  Our international members will benefit from methods to improve access to spine surgery, expand resources and advocacy for patients.  A more recent area of discussion in the committee has been the continuum of proper informed consent, discussion of risk, what constitutes competency and negligence and how to deal with legal implications in this regard.

The American Academy of Orthopaedic Surgeons (AAOS), together with the Board of Specialty Societies and the Quality and Patient Safety Action Fund, has made $50,000 available in grant funding.  The deadline is April 1, 2016.  Please go to http://www.aaos.org/AAOSNow/2016/Feb/Advocacy/advocacy4 for more information or contact Paul Zemaitis, MPH at [email protected].  Although the process is expected to be competitive, previous efforts from SRS members have been funded, so we should encourage our colleagues to pursue this important work.

There is mounting evidence that two attending surgeons operating together for complex adult deformity cases, 3 column osteotomies, etc. can reduce complications and improve outcomes (Sethi R, J Spine Deformity 2014 and Ames C, J Spine Deformity 2013).  This is commonplace among our colleagues in the UK and required by law for cardiac surgery in California.  Inherent with this approach come issues with payment, hospital administration / resources.  A white paper on the co-surgeon strategy will be forthcoming to help members navigate the payer issues and champion this approach at your institution.

If you have any suggestions, comments or questions for the committee, please email me at [email protected]

Chair: Suken A. Shah, MD Committee: Kit M. Song, MD, MHA; James O. Sanders, MD; Mark Weidenbaum, MD; Terry D. Amaral, MD; John R. Dimar II, MD; Mark A. Erickson, MD; Rajiv K. Sethi, MD; Michael G. Vitale, MD, MPH; David S. Marks, FRCS

Global Outreach Committee Update

Ferran Pellisé Urquiza, MD, PhD
Global Outreach Committee Chair

The Global Outreach Committee has defined three main priorities and is working hard to reach the established goals by the end of the year. Following efforts undertaken in previous years, a “GOP Road Map,” describing the transition between SRS-GOP candidate site and SRS-GOP self-sufficient site, is being defined.

Categories will reflect progress (activity and reporting) and commitment to accomplish the GOP mission statement. A new, simple and practical, GOP database focused on basic deformity, surgical technique descriptions and reports of neurological complications (M&M-compatible) should be available online before our Annual Meeting.  Finally, a paper describing one-year’s activity at SRS-GOP endorsed sites has been initiated. Our goal is to provide a general understanding of our patient demographic, available infrastructure, surgical techniques used, clinical outcomes and major complications.

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

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)

Evidence Based Outcomes Task Force Update

Douglas C. Burton, MD
Evidence Based Outcomes Task Force Chair

The Evidence Based Outcomes Task Force has been busy this past year working on a Systematic Review (SR) of pediatric spondylolisthesis.  This project is a follow-up to the SR done by the previous committee on pediatric spondylolysis. Our Task Force membership has overlapped with that of a parallel NASS Task Force that has performed an SR on adult spondylolisthesis.

The process began with a review of 1600 abstract titles culled from the literature search.  This was narrowed to 1000 abstracts, each reviewed twice for possible inclusion in the study.  From this, we chose 182 articles for the SR.  We plan to divide this project into three publishable manuscripts covering Natural History, Diagnostic Methods, and Treatment.  We plan to submit our work to Spine Deformity this summer.

Chair: Douglas C. Burton, MD Committee: James O. Sanders, MD; Shay Bess, MD; Charles H. Crawford III, MD; Tenner J. Guillaume, MD; Han Jo Kim, MD; A. Noelle Larson, MD; Matthew E. Oetgen, MD; Marilyn Gates, MD; Charles Ledonio, MD

3D Scoliosis Task Force Update

Carl-Eric Aubin, PhD, P.Eng
3D Scoliosis Task Force Chair

The 3D Scoliosis Task Force is continuing its main mandate of developing a 3D classification and surgical approach of adolescent idiopathic scoliosis, of promoting 3D analysis of scoliosis and of demonstrating the value of using 3D concepts.

A Lunchtime Symposium was organized during the 50^th Annual Meeting in Minneapolis to present state-of-the-art 3D principles involved in the management of scoliotic deformities, including practical take home knowledge covering 3D surgical tips and ways to better assess specific curves from a three-dimensional perspective.

A face-to-face meeting is planned in May or June to review a first version of a 3D classification (based on 3D clustering) and types of approaches using 3D criteria. The 3D Scoliosis Task Force is preparing a proposal for becoming a committee focusing on promoting 3D analysis of scoliosis and interpretation as the members of the committee believe there is a need to foster research and education on 3D spinal deformities.

Chair : Carl Eric Aubin, PhD, P.Eng; Stefan Parent, MD,PhD, Co-Chair Committee: Hubert Labelle, MD; Lawrence G. Lenke, MD; Roger P. Jackson, MD; Peter O. Newton, MD; Virginie C. Lafage, PhD

E-Text Committee Update

John C. France, MD
E-Text Committee Chair

E-Text is now available in an iBook format and can be downloaded from the SRS website onto any Apple device for $29.99 USD.  It will also remain available through the website and is available to nonmembers as well as members for viewing purposes.  It is a great tool for resident and fellow education on spinal deformity and I would encourage programs to incorporate it into their spinal education curriculum.

We have begun a rolling revision of each of the E-Text chapters.  Each chapter will be updated in a rolling fashion over the next three years with an anticipation that the E-Text will always be current within three years at all times.  Those of you that have contributed chapters may receive notification of the need for revision and we hope to make use of other members for contributions.  Many of the chapters simply require an update of current literature and/or techniques, but there may also be suggestions for enhancing the chapters with additional illustration, radiographs, photos or videos to continue to improve the product. There will also be five new chapters:

1. Neurologic Complications and Their Management
2. Proximal and Distal Junctional Kyphosis and Failure (Prevention Strategies and Treatment)
3. Anterior and Lateral Interbody Correction Techniques
4. Nomenclature in Spine Deformity
5. History and Physical Examination in the Spine Deformity Patient.

The table of contents is also in the process of being reorganized to create better grouping of chapters for ease of reference.  Videos are an area that could use a bolster and if anyone has or would like to create a good video to be incorporated into the E-Text, would be welcomed and should contact Ashtin Neuschaefer at [email protected] or myself. 

Chair: John C. France, MD Committee: Matthew P. Newton Ede, FRCS T&O; Patrick A. Sugrue, MD; Chris Chan Yin Wei, MS Orth; Sanjeev Suratwala, MD, FACS, FAAOS; Amer F. Samdani, MD; Mohammed M. Mossaad, MD

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:

23^rd IMAST: July 13-16, 2016 – Washington, D.C. USA
Marriott Marquis in Washington D.C., USA
Registration Opens: February 1, 2016
Registration Closes: June 15, 2016

51^st Annual Meeting & Course: September 21-24, 2016 – Prague, Czech Republic
Prague Congress Centre
Registration Opens: April 15, 2016
Registration Closes: August 20, 2016

2016 Spine Deformity Solutions: A Hands-On Course Schedule

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

SRS Worldwide Conferences

Nottingham, England
Regional Course with British Association of Spine Surgeons
April 6-8, 2016

Nanjing, China
In conjunction with Chinese SRS
April 9-11, 2016

Moscow, Russia
In conjunction with Russian Congress of Spine Surgery
May 27-28, 2016

Bali, Indonesia
In conjunction with Indonesian Spine Society
August 11-12, 2016

Hong Kong
Hands-On Tissue Training Course with Asia Pacific Spine Society
October 28-30, 2016

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

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