Summer
2007
| Topics |
Message from the Fellows Education Chairmen for DePuy Spine
D. Greg Anderson, MD; Carl Lauryssen, MD; Nathan Lebwohl, MD
Welcome to the Summer edition of the Future Leaders in Spine Surgery e-communication. We are pleased to bring you increased clinical content in this issue. Inside you will also find useful information for your clinical practice and your continued education, as well as business management tips and tricks. We encourage you take advantage of the clinical case challenge too!
We are honored and excited to have well-respected spine surgeons contribute their clinical experiences in many areas of spine pathology in this edition of the Future Leaders. A special thank you to Drs. Gupta, O’Brien, Shah, and Shufflebarger for their dedication to this program. We are certain you will find this content interesting and useful.
A reminder to those who are beginning a fellowship program this summer: there is still time to register for the 2nd Annual Advanced Concepts in Spine Surgery course with a focus on Minimally Invasive Spine Surgery, artificial disc replacement, and the business side of medicine. This course is scheduled to be held August 17-18, 2007 in Baltimore, MD.
For those of you who are out in practice and would like to sharpen your skills in the area of pediatric and adult deformity DePuy Spine is offering a course just for you, "Just Out in Practice, Now What?" The course chairmen, Munish C. Gupta, MD and Suken A. Shah, MD designed this course will to help you enhance your clinical practice.
For more information on these and other educational opportunities please click on the Medical Education link on the right side of this page.
As the Fellows Education Chairmen for DePuy Spine we would like to take this time to share with you the passion that DePuy Spine has for education and for the spine community. We encourage you to take full advantage of the program offerings. We stand by the effectiveness and quality of the programs.
Should you need any support or assistance with your practice or your fellowship we are here for you. Please feel free to contact any one of us for support. Our contact information is listed below.
| D.
Greg Anderson, MD Thomas Jefferson University davidgreganderson@comcast.net |
Carl
Lauryssen, MD Olympia Health Center drcl@olympiamc.com |
Nathan Lebwohl, MD University of Miami nlebwohl@aol.com |
Message from DePuy Spine Management Board
Max Reinhardt, Vice President US Sales At DePuy Spine our vision is [To be the most trusted and respected spine company in the world.]
Spine surgery is a highly evolutionary discipline. As the second largest manufacturer of spinal instruments and implants in the world we are focused on providing the highest quality professional education. Every year DePuy Spine conducts over 300 training events that attract hundreds of surgeon delegates; at this time many of you have education as your number one priority, and as you progress through your programs and careers, it is important that you know my colleagues and I at DePuy Spine are here to support you.
The future of spine surgery is dependant upon strong collaboration between surgeons and industry. As you are the spine surgeons of the future, we are truly committed to building a long, rewarding, and exciting working relationship with you to ensure that together we can positively impact the lives of patients with spinal pathology.
I trust that you will enjoy this edition of Future Leaders e-communication and I welcome your feedback and suggestions on what is of value to you.
Personally I feel privileged to work with spine surgeons who, in my experience, are passionate, creative people with a zest for life. The future of spine surgery is dependent upon your development as leaders in this discipline - good luck!
Clinical Forum
Spinal Deformity: Tips and Tricks Harry L Shufflebarger MD, Miami, FL
Vertebral Level Determination during Surgery In any spinal surgery, exact determination of vertebral levels is mandatory. Many methods have been employed to determine what levels are exposed, instrumented, and fused. Anatomic methods have been employed. Identification of the short transverse process on thoracic 11 and the mamillary body of thoracic 12 have been helpful in level determination. The change in facet orientation at the thoracolumbar junction has also been of value. However, these anatomic landmarks are not 100% constant and reliable as determinants of vertebral levels.
Radiographic methods have also been used. Usually an instrument (towel clip or Kocher clamp) is placed on a spinous process and a plain radiograph made. This may be difficult to interpret as the spinous process and vertebral body are not always easily identified. And, it takes time to process the radiograph.
An infallible method employs image intensification. The C-arm is used in all deformity cases, and is always in the room and draped. The 12th thoracic vertebra (or 11th or 1st lumbar) is tentatively identified. An awl is then placed at the entrance to the pedicle. This area is viewed on AP fluoroscopy. By observing the ribs and the pedicle with the awl, accurate identification of the level is assured, as illustrated below.
Juvenile Rheumatoid
Arthritis Case History & Summary of Spinal Manifestations Joseph O’Brien, MD
Johns Hopkins University, Baltimore, MD
Case History:
History and Examination
A 15 year-old male presented to the emergency department with a chief complaint of neck pain after sustaining a fall from standing. His past medical history was significant for systemic juvenile rheumatoid arthritis (JRA) diagnosed at age 8. His medical sequalae from JRA included pericarditis, avascular necrosis of his left hip and boutonniere deformity of his digits. On examination, he had posterior midline tenderness, but no neurologic deficits. His reflexes were normal. No pathologic reflexes were present and sensation was normal as well.
Radiographic Studies
Computed tomography (CT) and magnetic resonance imaging (MRI) of his cervical spine demonstrated atlanto-axial subluxation with rheumatoid panus (figures 1-4). The space available for the spinal cord at C1-C2 was 6mm as measured on CT scan. Extension radiographs showed that the atlanto-axial interval was not reducible (figure 5). Posterior instrumentation and fusion was recommended.
 Space Available for Cord 6mm |
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Operative Treatment
A standard posterior approach was made to C3-C1. Subperiorsteal dissection was performed using monopolar cautery starting at the lateral mass of C3 and proceeded rosterally to expose the posterior elements of C2 and C1. Bipolar cautery and a Penfield number 1 was then use to expose the arch of C1 1.5 centimeters from midline bilaterally. Dissection along the pars of C2 then proceeded along its medial and superior borders using an irrigating bipolar. After exposure of the pars of C2, attention was directed at exposing the C2 nerve root.
Dissection then proceeded under the C2 nerve root using irrigating bipolar cautery until the C1-C2 joint was exposed. Attention was then directed to the inferior border of the C1 arch. Preoperative measurements on the CT scan showed that the center of the lateral mass was 1.2 cm from midline. This roughly corresponded to point where the arch met the inferior portion of the lateral mass. This was palpated with a Penfield number four and irrigating bipolar electrocautery was used to expose the lateral mass of C1.
A posterior cervical fusion was performed. X-ray was used to confirm reduction of C1 and C2. The wound was irrigated. Interoperative neuromonitoring showed excellent signals. The patient awoke and was found to be in excellent condition with 5/5 strength in all myotomes. Postoperative CT scans showed excellent reduction.
Introduction and Classification
Childhood arthritis is the most common chronic disease of childhood3. According to the International League of Associations for Rheumatology (ILAR) criteria, the term juvenile rheumatoid arthritis has given way to juvenile idiopathic arthritis (JIA) as part of a larger classification, which includes ankylosing spondylitis and psoriatic arthritis5. JIA is subclassified according to onset, associated sequalae, and the presence of blood markers (HLA-B27, Rheumatoid Factor).
Table 1 lists the subtypes of JRA and JIA. Regardless of classification, one or more joints must be affected for at least 6 weeks with an age of onset less than 16 years for the diagnosis to be made3,5.
For the purpose of clarity, JRA will be discussed in this review.
| Juvenile Rheumatoid Arthritis | Juvenile Idiopathic Arthritides |
| Systemic | Systemic |
| Polyarticular onset |
Polyarticular, RF negative |
| Polyarticular, RF positive | |
| Pauciarticular onset |
Oligoarthritis |
| Oligoarthritis, extended | |
| Enthesitis-related arthritis | |
| Psoriatic Arthritis |
Table 1: Nomenclature for childhood arthritis. RF, rheumatoid factor.
Epidemiology
JRA is more common in females than males. In a series reported by Hensinger, et al, 69% of the patients were female (1986). The overall incidence of JIA is 5-18/100,000 with a prevalence of 1 per 1,000 children6.
Presentation
Juvenile rheumatoid arthritis presents on average at 6 years of age1,3. This presentation varies according to the subtype, for instance, pauciarticular patients tend to present at a younger age. In a study of 121 children with JRA, 11% had systemic arthritis, 42% had polyarthritis, and 47% had pauciarticular disease1. The subtypes present differently and have different manifestations of the disease with respect to the spine.
Systemic JRA presents with daily spiking fevers and one or more of the following: rash, myalgias, generalized lymphadenopathy, hepatosplenomegaly, and serositis (inflammation of the pleura, pericardium, or peritoneum)3. Joint arthritis may present long after the systemic manifestations of disease.
Pauciarticular JRA is the most common subtype. It tends to present earlier (1-4 years of age). Between 1-4 joints will be affected by the disease. Approximately 20% of children will develop anterior uveitis3,6. One should examine the child’s pupils to ensure that they are round. If they are not, referral to ophthalmology should be made.
Polyarticular JRA is defined by having 5 or more joints affected within the first 6 months of disease. Uveitis may occur, but at a much lower incidence than pauciarticular JRA6.
It is important to note that a large proportion of children with JRA will have disability into adulthood. Approximately half will have active arthritis 10 years after diagnosis6. Up to 17% will require a walking aid. In addition to the appendicular manifestations, many children will develop changes in the spine.
Spinal manifestations
Involvement of the cervical spine is more common in JRA, while the lumbar spine is involved mostly with ethesiopathy-related arthritides (ankylosing spondylitis)1,3,6.
With regard to the cervical spine, Hensinger, et al, described seven characteristic changes.
- Anterior erosion of the ondontoid process
- Anterior-posterior erosion of the odontoid (apple core ondontoid process)
- C1-C2 instability
- Calcification of the leading edge of the anterior aspect of the ring of C1
- Posterior fusions
- Growth abnormalities (preceeded by posterior fusions)
- Subaxial subluxations
In the lumbar spine, one may encounter sclerosis of the vertebral corners, loss of disc height, syndesmophyte formation or bony ankylosis (as with ankylosing spondylitis). In children with chronic steroid use, compression fractures or osteopenia may be notable in the thoracic and lumbar spine2. Sacroilitis may be noted as well. Magnetic resonance imaging may show marrow edema and enhancement around the joint space.
In summary, JRA is a common disease of childhood. Children presenting to the practicing spine surgeon should have their cervical spine imaged to rule out instability.
References:
1. Hensinger R. DeVito P. Ragsdale C. Changes in the Cervical Spine in Juvenile Rheumatoid Arthritis. JBJS, 68-A(2): 189-97. 1986
2. Johnson K. Imaging of Juvenile Idiopathic Arthritis. Pediatr Radiol 36: 743-59. 2006
3. Jordan A. McDonagh JE. Juvenile Idiopathic Arthritis: the paedriatric perspective. Pediatr Radiol 36: 734-42. 2006.
4. Nathan FF. Bickel WH. Spontaneous Axial Subluxation in a Child as the First Sign of Juvenile Rheumatoid Arthritis. JBJS. 50-A(8). 1675-9 1968.
5. Petty RE. Shoutwood TR. Manners P, et al. International League of Associations for Rheumatology Classification of Juvenile Idiopathic Arthritis: second revision, Edmonton, 2001. J Rheumatol. 31: 390-92.
6. Sherry, DD. What’s New in the Diagnosis and Treatment of Juvenile Rheumatoid Arthritis. Journal Pediatric Orthopaedics. 20(4): 419-20. 2000.
7. Symmons DP. Jones M. Osborne J. Et al. Pediatric Rheumatology in the United Kingdom: data from the British Paediatric Rheumatology Group National Diagnostic Register. J Rheumatol 23: 1975-80.
8. Wallace CA. Current Management of Juvenile Idiopathic Arthritis. Best Practice &Research in Clinical Rheumatology. 20(32) 279-300. 2006.
What’s in my Bag?
An interview with Suken A. Shah, MD, AI DuPont Hospital for Children DS: How important is the versatility of a spine system when determining your approach to treating complex spinal pathologies?
SS: "Versatility, apart from reliable support from the local sales force and the manufacturer, is probably the single most important feature of a spine system for a surgeon that treats complex spinal pathologies, such as deformity, trauma and tumor. The EXPEDIUMDS: Talk a little bit about design history/lineage, and how that impacts your decision with respect to using a particular spine system?Spine System’s breadth allows any surgeon to mix and match various implant types (screws, hooks, wires), reduction options and correction techniques and thus, does not dictate one way to treat all pathologies. Furthermore, there are choices available for metal (stainless steel or titanium) and rod diameter (6.35 mm, 5.5 mm and soon, 4.5 mm). From T1 to the sacropelvis, it can get the job done with ease."
SS: "The EXPEDIUM Spine System, at its foundation, is based on MOSSMiami and has incorporated features of ISOLA
DS: Oftentimes surgical technique is limited by the capabilities of instrumentation. What has your experience been with the EXPEDIUM Spine System, and do the instruments and implants facilitate your surgical goals?
SS: "On the contrary, EXPEDIUM has afforded me possibilities that push the envelope in terms of correction capability of even the most rigid, severe scoliosis. My experience with the system has been a pleasure; there is really no case that I feel will surmount the capabilities of the system. My favorite innovations of the system are the top notch feature, the uniplanar screw and the high strength stainless steel rods. The top notch feature allows the reduction tools to easily capture the screw head and facilitate engagement with the rod. The uniplanar screw accommodates the sagittal plane, but still allows control of the coronal and axial plane for correction and derotation; the derotation instruments attach intuitively to the screw heads and securely transfer corrective forces. The higher strength stainless rods have truly redefined control of severe deformities."
DS: What are some of the most common challenges you face intra-operatively when correcting complex deformities, and how has your spine system-of-choice helped you to mitigate these issues?
SS: "The most common challenges I face in pediatric spinal deformities are sagittal plane issues in the thoracic spine, correction of pelvic obliquity and small stature patients. In adolescent idiopathic scoliosis, a goal is to restore thoracic kyphosis to the scoliotic spine, which at the apex of the curve may be lordotic; the EXPEDIUM uniplanar screws and high strength rods have been very helpful in this effort. Correction of pelvic obliquity and rigid pelvic fixation in neuromuscular scoliosis, until now has been elusive. The various sacropelvic implant options and pelvic obliquity control apparatus will set the system apart from anything available. Young patients and those with skeletal dysplasias requiring instrumentation pose challenges with implant size and prominence; EXPEDIUM 4.5 mm will offer a superior solution for the small patient with challenging spinal pathology with virtually every implant style and feature in the current EXPEDIUM line.The educational opportunities offered by the company for complex pathology do an excellent job of teaching the newest surgical techniques and proper use of the instrumentation that fill a doctor’s bag with everything needed to treat this spinal pathology.
A Look Back – 2007 Educational Events Highlights
2007 Pre-Fellowship Bioskills Workshop
In April and May of this year DePuy Spine hosted the 4th annual Pre-Fellowship
Bioskills Workshop. By all accounts this was the most successful year yet! This unique course is designed specifically for the incoming 2007-2008 spine fellows. Participation is limited to fellows who are attending programs that are supported in part by educational grants from DePuy Spine this academic year.
During the course, the participants had the chance to learn surgical techniques and anatomic approaches from their fellowship directors and other instructors prior to beginning their fellowship year. The goal of this program is to enhance the participants’ surgical skills and accelerate their progress along the learning curve. This training course is designed to comprehensively cover anterior and posterior approaches to the cervical, thoracic and lumbar spine.
This year DePuy Spine contributes to approximately 38 fellowship programs, which include nearly 70 fellows. Given the large number of faculty and participants this workshop was hosted on two different weekends this year.
Each course was very well attended, with approximately 19 faculty members and 21 participants in Las Vegas and 22 faculty members and 28 participants in St. Louis. The participants truly appreciated the opportunity to participate in this unique educational opportunity!
A Look Ahead – Upcoming Education / Events
Date |
Meeting |
Location |
Faculty (if applicable) |
Website (if applicable) |
| Aug. 16-18, 2007 |
*DePuy Spine Advanced Training for Spine Fellows: MIS & Artificial
Disc Replacement |
Baltimore, MD |
D. Greg Anderson, MD; Carl Lauryssen, MD; Nathan Lebwohl, MD |
|
| Aug. 24, 2007 |
*DePuy Spine CHARITÉ
Artificial Disc Bioskills Workshop |
Raynham, MA |
Scott Blumenthal, MD; Mitch Hardenbrook, MD |
|
| Sept. 4-8, 2007 |
Scoliosis Research Society Annual Meeting |
Edinburgh, Scotland |
|
View Website |
| Sept. 15-20, 2007 |
Congress of Neurological Surgeons Annual Meeting |
San Diego, CA |
|
View Website |
| Sept. 27-28, 2007 |
*Advanced MIS Training Program |
Baltimore, MD |
D. Greg Anderson, MD |
|
| Oct.5-6, 2007 |
*Deformity Post-Fellowship Training Program |
San Francisco, CA |
Munish C. Gupta, MD; Suken A. Shah, MD |
|
| Oct. 23-27, 2007 |
North American Spine Society Annual Meeting |
Austin, TX |
|
View Website |
| Nov. 1-2, 2007 |
*Spinal Deformity Tutorial |
San Diego, CA |
Peter Newton, MD |
|
| Nov. 8-9, 2007 |
PAWS: Current and Emerging Issues in Complex Lumbar Spine Course |
St. Louis, MO |
|
View Website |
| Nov. 8-10, 2007 |
AAOS: Contemporary Issues in Spine Surgery Course |
Rosemont, IL |
|
View Website |
| Nov. 28-Dec. 2, 2007 |
International Pediatric Orthopaedic Symposium (IPOS) Annual Meeting |
Orlando, FL |
|
View Website |
*For more information regarding DePuy Spine Medical Education events please contact the DePuy Spine Medical Education department at 1-800-741-8075.
The DePuy Spine Medical Education Team, in
partnership with Axial Biotech, is pleased to present an interactive
symposium:
Pioneering the Treatment Options for Adolescent Idiopathic Scoliosis: Prognostic Genetic Testing
Esteemed faculty for the event includes John Braun, MD, Robert Campbell, MD, Peter O. Newton, MD, James Ogilvie, MD, Suken Shah, MD, Kenneth Ward MD and Brad Williamson, MD.
Please join us at the Mansfield Traquair Centre in Edinburgh, Scotland on Thursday, September 6, 2007 from 6:30 to 8:00 PM. Those interested in attending, should contact Rebecca Staaf at rstaaf@dpyus.jnj.com, or DePuy Spine’s Medical Education Hotline at 1-800-741-8075.
Pioneering the Treatment Options for Adolescent Idiopathic Scoliosis: Prognostic Genetic Testing
Esteemed faculty for the event includes John Braun, MD, Robert Campbell, MD, Peter O. Newton, MD, James Ogilvie, MD, Suken Shah, MD, Kenneth Ward MD and Brad Williamson, MD.
Please join us at the Mansfield Traquair Centre in Edinburgh, Scotland on Thursday, September 6, 2007 from 6:30 to 8:00 PM. Those interested in attending, should contact Rebecca Staaf at rstaaf@dpyus.jnj.com, or DePuy Spine’s Medical Education Hotline at 1-800-741-8075.
Medical Education Summer Highlights
CALLING ALL 2007-2008 SPINE FELLOWS! SAVE-THE-DATE FOR THE 2nd ANNUAL ADVANCED TECHNIQUES BIOSKILLS WORKSHOP!August 17-18, 2007, Baltimore, MD
On behalf of the Fellows Education Chairmen for DePuy Spine you are cordially invited to attend the 2nd Annual Advanced Techniques Bioskills Workshop featuring Minimally Invasive Spine Surgery (MIS) and Disc Replacement Techniques. It is scheduled on August 17-18, 2007, at the VISTA lab in Baltimore, MD.
This unique course is designed for fellows who will be starting a spine fellowship supported in part by DePuy Spine in the 2007-2008 academic year. The course will feature a comprehensive review of MIS surgery in a cadaver-based learning environment, a half-day session demonstrating surgical techniques for lumbar disc replacement surgery, and a half-day dedicated to the business-side of medicine.
Don’t miss this wonderful opportunity! For more information please contact Dianne Anderson in the DePuy Spine Medical Education department at 508 828-3679 or via email.
SAVE THE DATE FOR A NEW, EXCITING COURSE DESIGNED SPECIFICALLY FOR YOU!
October 5-6, 2007; San Francisco, CA It is our pleasure to invite you to a new course offering sponsored by DePuy Spine for the Future Leaders in Spine Surgery. "Just Out in Practice...Now What?" will take place in San Francisco, CA, on October 5-6, 2007.
The course will have a pediatric and adult spinal deformity focus with a world-class faculty. Topics will include early onset scoliosis, AIS, adult deformity including the sagittal plane, complications, and the latest surgical techniques by the masters in deformity.
In addition to the clinical aspects of medicine there will be planned sessions on contracts, practice management, the business of medicine, performing good research, how to use outcomes instruments, time management, and philanthropy.
There will be ample time for informal interaction with the faculty members and case presentations. Whether you are in private practice or an academic setting, this course is for you!
We sincerely hope you can join us in the City by the Bay this October!
To register please go to www.spineeducationresources.com/registration or contact your local DePuy Spine Sales Representative.
Winners of Spine Case Challenge #2 can choose to have DePuy Spine pay for their travel expenses to attend this meeting, up to $1,000! Register today!
For more information please contact Stephanie West in the DePuy Spine Medical Education Department. She can be reached at 508 828-3680 or via email.
Course Chairmen:
Munish C. Gupta, MD, UC Davis Medical Center
Suken A. Shah, MD, AI DuPont Hospital for Children
Must Read Clinical Articles – Suggestions from the Fellows Education Chairmen
To obtain a free copy of these articles simply click on the link below.The Efficiency of Gabapentin Therapy in Patients with Lumbar Spinal Stenosis, Yaksi, et al. Spine. 32(9):939-942, April 20, 2007.
Read Article...
Surgical vs. nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial, Weinstein, et al; JAMA. 2006 Nov 22;296(20):2441-50
Read Article...
Surgical or Nonoperative Treatment for Lumbar Spinal Stenosis? Malmivaara, et al. Spine. 32(1):1-8, 2007.
Read Article...
The Spine Patient Outcomes Research Trial Results for Lumbar Disc Herniation: A Critical Review, Paul C. McCormick, MD, MPH, Journal of Neurosurgery, 6:513-520, 2007
Read Article...
Nonoperative Treatment for Lumbar Disk Herniation, Andrew J. Haig, JAMA / April, 2007 / volume: 297 (pages: 1545 - 1545)
Read Article...
Surgical Treatment of Lumbar Disk Disorders, Eugene Carragee, MD; JAMA. 2006;296:2485-2487
Read Article...
DePuy Spine in the Journals
As part of our commitment to further the clinical evidence in the spine community, we are proud to offer the following clinical research articles that further support the use of our products. To obtain a free copy of these articles simply click on the link below.
Derotation of the Spine, Shah SA Neurosurgery Clinics of North America, 18(2): 339-345, April 2007
Read Article...
Practice Related Tips & Tricks
Jennifer Beaver, Zupko & AssociatesSurgeon Decoder Kit for EOB’s
KarenZupko & Associates, Inc.
www.karenzupko.com
Surgeons Decoder Kit for EOBs
Given the complexity of today’s reimbursement process and ever-changing coding rules it can seem impossible to get paid for services. But surgeons need look no further than the payment/denial notices sent by plans in response to physician claims. These documents, called EOBs – explanation of benefit forms - hold the key to understanding and monitoring payment.
What can EOBs tell a surgeon?
- Which surgical code combinations are being paid
- Which surgical code combinations are not being paid, prompting a discussion of whether appropriate modifiers were included/are needed
- If operational issues are interfering with reimbursement; examples include no pre-authorization obtained prior to the procedure, no referral obtained prior to a visit, claim not submitted in a timely fashion, or requested information such as notes or test results not submitted to support services.
- Whether surgical assist and/or co-surgeon services are recognized and paid properly.
- Whether the plans recognize add on codes and pay them at full value as they are not subject to multiple procedure discounts.
KZA recommends surgeons review 15 surgical case EOBs each month; these should include those with payments and those with denials. Fellows and surgeons in private practice should be able to easily request copies of EOBs from the administrator. Those in hospital or academic settings may not be able to obtain the actual hard copy EOB printout, but can often receive a file of the same information listed in a Microsoft
Excel spreadsheet. Physicians in both practice settings will need an introduction
to the information they are reviewing, but that is especially true for those receiving
an electronic file as the headers may not be clear. When reviewing EOBs surgeons should focus on the claim adjustment reason and remittance advice remark (i.e., denial) codes. It is these codes and their definitions which are usually provided at the end of the EOB, that alert surgeons to reimbursement or coding problems. If EOBs do not include a "key" to decipher the codes, they can be referenced at the following website: http://www.wpc-edi.com/codes (click on claim adjustment and remittance advice links and check both lists).
Ongoing education is the logical next step in the continuous improvement cycle of coding and reimbursement education. Both NASS and the AANS offer coding courses which review spine coding and reimbursement issues in depth. While the NASS course for the year was offered in March this year, the AANS offered the first advanced course on June 29-30) and the next one is slated for August 24-25, and the introductory course for September 7-8, 2007 (visit http://www.aans.org/education/educational/07coding_courses.asp ).
Bonus – NPI Update!
In the last issue of Practice Related Tips & Tricks we discussed the importance of obtaining an NPI – national provider identifier – and the fact that delays in deadlines were possible.
Although over 2 million NPIs have been issued, some providers and plans were not prepared for the May NPI deadline. In addition, errors in the new CMS 1500, which was to be mandatory at about the same time as the NPI implementation, resulted in concerns about timely claim processing and payment. As a result, CMS and many other plans issued contingency plans which require that claims for services be submitted with BOTH the NPI and the physician’s former provider ID number. Contact your insurance plans to see their requirements, which may or may not mirror CMS requirements. Plans will notify providers when they may begin submitting claims with just the NPI; Medicare notes it may provide such notification as early as July 1, 2007.
Remember that individual physicians, as well as private practice groups, must obtain an NPI. Visit https://nppes.cms.hhs.gov to apply for an NPI. In addition, physicians are encouraged to share their NPIs with other physicians and health care entities when requested. CMS has also announced it will create an online searchable database of physician NPIs.
DePuy Spine 2nd Annual Clinical Research Paper Challenge
We are very pleased to announce the launch of the 2nd Annual DePuy Spine Clinical Research Paper Challenge. The goal of this exciting contest is to support and encourage clinical research endeavors that will increase the clinical data available to surgeons and patients, helping to maximize spinal surgeon awareness and patient care.This Challenge is open to all spine surgery fellows currently enrolled in a fellowship program supported in part by DePuy Spine, as well as all spinal surgeons who completed a fellowship program supported in part by DePuy Spine within the last three years. We invite you to take part in this exciting new program. Your participation will contribute to the development of a much-needed fact-based approach to spinal surgery through the dissemination of clinical data.
You should have received the details of the challenge via email on August 1, 2007.
If you have any questions please contact Stephanie West via email or at 508 828-3680.
1st Annual DePuy Spine Clinical Research Paper Challenge
Research Paper Award WinnersThank you to all who participated!
1st Place: Paul Khoueir, MD
Multi-level anterior cervical fusion using a collagen-hydroxyapatite matrix with iliac crest bone marrow aspirate: an eighteen-month follow-up study
2nd Place: Christopher Heck, MD
Morbidity or mortality rates for geriatric odontoid fracture: hard cervical collar versus Bremer HALO
cervical vest immobilization 3rd Place: Thomas Roush, MD
Analysis of hybrid arthroplasty / fusion constructs in the lumbosacral spine: a comparison with 2-level arthroplasty or fusion
*Please note – this paper evaluates the use of the CHARITE
Artificial Disc in a clinical application not currently approved by the FDA. The CHARITÉ Artificial Disc is indicated for spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) at one level from L4-S1. DDD is defined as discogenic back pain with degeneration of the disc confirmed by patient history and radiographic studies. These DDD patients should have no more than 3mm of spondylolisthesis at the involved level. Patients receiving the CHARITÉ Artificial Disc should have failed at least six months of conservative treatment prior to implantation of the CHARITÉ Artificial Disc.
CONGRATULATIONS to all! We look forward to reviewing your papers next year!
Papers Submitted and Accepted for Publication:
Paul Khoueir, MD
Multi-level anterior cervical fusion using a collagen-hydroxyapatite matrix with iliac crest bone marrow aspirate: an eighteen-month follow-up study
Deadline for submission to publication is December 2008
Abstracts & Posters Submitted and Accepted at Major Spine Society Meetings:
Paul Khoueir, MD
Multi-level anterior cervical fusion using a collagen-hydroxyapatite matrix with iliac crest bone marrow aspirate: an eighteen-month follow-up study
Spine Case Challenge #2
Submitted by Munish C. Gupta, MDSan Francisco, CA
T ake a multiple-choice test. Correct answers will be entered into a drawing for valuable educational prizes. Deadline is September 15, 2007.
17-year-old male jumped into pool headfirst. Patient had neck pain and sought care from a chiropractor. Three weeks later he presents to the emergency department with weakness in left deltoid and left arm pain. No motor weakness in the lower extremities. Images done in emergency department are shown.
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1. What is the diagnosis?
A. Congenital deformity2) What is the most appropriate first step in management in the emergency department?
B. Unilateral facet dislocation
C. Bilateral facet dislocation
D. Bilateral perched facets
A. Halo application3) Further management of this injury should consist of?
B. MRI
C. Closed reduction with fluoroscopy
D. Flexion and Extension radiographs
A. Cervical orthosis and close follow-up
B. Manipulation under sedation in emergency department
C. Open reduction and application of halo
D. Open reduction and fusion with instrumentation
Winners of Spine Case Challenge #1
Thank you to all who participated in the 1st Spine Case Challenge! Just for participating you will all receive a small gift of appreciation. The correct answers to the multiple choice questions are as follows:70-year-old woman with rheumatoid arthritis who presents with mild neck discomfort and a complaint of progressive heaviness in her extremities. She ambulates without the assistance of a walker. Her motor strength is good throughout, with no focal deficits, and her reflexes are remarkable only for a Hoffman's sign bilaterally.
1) How would you manage this case?
A) odontoid resection2) What percentage of patients with rheumatoid arthritis undergoing total joint replacement of the knee or hip have radiographic evidence of atlantoaxial instability without any complaints of neck pain or myelopathy?
B) occipital cervical fusion
C) occipital cervical fusion and C1 laminectomy
D) C1-C2 fusion
A) 15%3) In a patient with rheumatoid arthritis who has no neck pain or myelopathy, but has radiographic evidence of atlantoaxial instability, what radiographic parameter is most useful for determining whether surgical intervention is needed?
B) 50%
C) 80%
A) Anterior Atlanto-Dens interval greater than 5mmAnd the winners are...
B) Posterior Atlanto Dens Interval less than 14mm
Todd Jackman, MD, University of Minnesota
Kamran Majid, MD, Brooklyn, NY
Joseph O’Brien, MD, Johns Hopkins University
Alpesh Patel, MD, University of Utah
Avraam Ploumis, MD, Greece
Andrew White, MD, Thomas Jefferson University
Seth Williams, MD, University of Miami
Next Quarter...
Key highlights:- Looking for a job? The top 10 things you need to know
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- How can you differentiate your practice?
- And more...
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