Screw Misplacement in 70% of Cases?!…NASS Going on the Offensive Re: Coverage…BS and Stalling From Insurers…Sumit Dewanjee, M.D. Honored With 4th Consecutive Patient’s Choice Award…and more.
Screw Misplacement in 70% of Cases?!
Researchers from New York have just presented their paper, “Burying One’s Head in the Sand: Are We Underestimating the Significance of Pedicle Screw Misplacement?” Terry D. Amaral, M.D. is chief of pediatric orthopaedic surgery, at Montefiore Medical Center and assistant professor of surgery at Albert Einstein College of Medicine. He tells OTW, “We have ‘come a long way, baby’ as far as fixation, and there is now a push to do all of these surgeries as pedicle screw constructs. More and more we need to make sure that what we are doing is safe. The spinal cord is right next to where we are putting the screws in; we are also working near where the nerve roots exit…if you perforate that area the patient will experience weakness or even paralysis. Then in the front of the spine there are other things to be concerned about, like the aorta, the vena cava, the lungs, etc. Even world renowned surgeons are only attaining accuracy rates of 87-92%. If you have 100 patients and you’ve put screws in 12 vertebrae, that is 24 screws in each patient; so you’re looking at 2, 400 pedicles…but that is making all patients into one group. If you have 10% inaccuracy, then that means that 2 out of 20 screws could be misplaced. Amazingly, we found that as many as 70% of patients may have a screw misplaced. Thankfully, most screws are just misplaced by a millimeter or two out the front or are slightly off medially, so they are not doing real damage. However, 5-10% of those misplaced screws are cause for concern.”
“To rectify this, we must have access to imaging devices during the procedure. We are beginning to look at intraoperative CT-scans and checking to see how accurate they are as compared to CT-scans done in a radiology suite. With intraoperative scans we can control how much radiation we are using; we are taking digital data and maximizing it with software. The software is able to interpret that digital information and give us better images. So the race is on to see which company can perfect the software. We’ve talked with Medtronic and they have significantly improved algorithms of translating that data so we can use a much lower dose of radiation. We are performing blinded, cadaveric studies, purposely misplacing the screws, and using an O-arm for imaging. Then we are putting the cadavers through a standard CT-scan and comparing the two. We also think that this software can be used for navigation where screw placement is done with the aid of a computer. In theory this might give us a military level accuracy. This is critical stuff…remember, if you’re off by ‘only’ a few millimeters then you’re in the aorta.”
NASS Going on the Offensive Re: Coverage
Chris Bono, M.D., chief of spine at Brigham and Women’s Hospital, Treasurer of the North American Spine Society (NASS), and Deputy Editor of The Spine Journal will be presenting at the upcoming Spine Summit on August 10, 2012 in Burr Ridge, Illinois. He tells OTW, “We will be working on a major new effort, a coverage committee for NASS, so that we can proactively develop coverage policies and not always be responding to policies. We will compile a list of things we think are at risk of being cut by insurers in the future. For example, take bone graft substitutes…there have been so many brought to market without any clinical data. We will keep it generic so that it’s not specific to any certain manufacturer. Then we will develop our own suggestions for moving forward. The challenges will be that for many procedures there is just not a lot of evidence and so we are having trouble building sound justification for their use. Policies are becoming so restricted that I recently had a patient with cervical myelopathy denied surgery. This is unheard of because this is a condition with no nonoperative treatment—it must be treated surgically. They are really playing games now.”
Remarkable Gait Analysis Results at AOFAS Meeting
David B. Thordarson, M.D. is professor of orthopaedic surgery at the University of Southern California and editor-in-chief of Foot & Ankle International. He found a lot to like at the recent American Orthopaedic Foot and Ankle Society meeting. Dr. Thordarson told OTW, “There were several standouts, including work by Tim Daniels, M.D. and the Canadian Orthopaedic Foot and Ankle Society comparing total ankle replacement to fusion. They found that when looking at gait analysis, those patients who had a replacement had a slightly better gait pattern at midterm—and they had excellent pain relief. Essentially, with a more normal gait there is less stress on the adjacent joints in the foot and that should mean less arthritis. But those replacements are going to wear out. When a hip or knee fails, it involves larger bones so you take the joint replacement out and put in a new one. In the ankle, however, if it fails there is bone loss around the prosthesis and there is often little to put a new prosthesis into. An ankle replacement should be performed at a higher threshold than knee or hip because the alternative is knee or hip fusion, both of which are horrible. The alternative to an ankle replacement is fusion…and you can still walk without a limp.”
Francis Y. Lee, M.D.: Four Years of R01 Funding
Columbia Orthopaedics has announced that Francis Y. Lee, M.D., Ph.D., vice chairman for research, associate professor of Orthopaedic Surgery with Tenure, chief of Musculoskeletal Oncology, director, Center for Orthopaedic Research, and Columbia University Senator has obtained his third National Institutes of Health Grant. The National Institute of Biomedical Imaging and Bioengineering has awarded a $1.44 million, four year renewal of Dr. Lee’s first R01 grant, “Mechanobiological Mechanism for Inflammatory Bone Loss.” Dr. Lee completed three fellowships in Pediatric Orthopaedic Surgery, Musculoskeletal Oncology and Research. Additionally, he has been serving on NIH review panels and American Board of Orthopaedic Surgery committees.
BS and Stalling From Insurers
A spine surgeon friend tells OTW, “Despite so much progress we are still being hammered by the insurance companies about different criteria for fusions. It’s frustrating for surgeons because there is good data and there are surgeons doing bad things. We operate on a different standard than heart doctors, who in many cases only have to perform one surgery. Ideally, in orthopedics one surgery would be sufficient, but as we grow older things change. Insurers don’t hold heart doctors to this standard of ‘no repeat surgeries.’ Insurance companies don’t care; they say they didn’t approve XYZ surgery because it didn’t work. But patients only stay with an insurance company for an average of 18 months before they change carriers. So the insurers don’t give a damn because some other carrier will be taking care of them. They tell patients, ‘We will pay for anything reasonable.’ They tell doctors to write up the situation; they are just stalling the patient. They say, ‘There is not enough peer reviewed literature.’ That is BS! Over 12 years Charité and other products have proven themselves…these are not experimental. The issue comes down to power and money. In approximately 2003 I spoke with a PR firm in Washington, D.C. and I asked, ‘How much money is the insurance lobby spending?’ Forty million dollars was the response. When I asked what doctors would need to spend to make a dent in their efforts, the PR people said, ‘$8 million.’ Keep in mind that this was about ten years ago. Today we would probably need to spend $80 million to make a real difference.”
Sumit Dewanjee, M.D. Wins Fourth Consecutive Patient’s Choice Award
Sumit Dewanjee, M.D., a Board Certified and Fellowship Trained Mesa orthopedic surgeon, has been honored with his fourth straight Patient’s Choice Award. The award is based upon patient ratings, bedside manner, doctor expertise, and time spent with the patient. This honor is only conferred upon the top 5% of over 800, 000 doctors across the U.S. Dr. Dewanjee is fellowship trained in sports medicine and maintains additional specialty interest in trauma. The fellowship entailed an extra year of training specifically in shoulder and knee sports surgery working with athletes on complicated cartilage, tendon, and ligament surgeries. This included cartilage transplant procedures, meniscal repairs, rotator cuff repairs, and fracture repair. He is an expert in arthroscopic surgery.
