The recently completed meeting of the Society for the Advancement of Spine Surgery (SAS) in New Orleans left many vendors and exhibitors muttering about a “dead” meeting and the lack of spine surgeons visiting their exhibits.
Thomas Errico, M.D.
President, SASIncoming President Thomas Errico, M.D., told OTW on May 6 that a gathering of over 650 spine surgeons was not exactly a small meeting. But quite candidly, he acknowledged that the time has come for the society to look for new ways to bring industry and spine surgeons together in a way that highlights new and innovative surgical technologies.
Indeed, SAS reported to OTW that meeting attendance fell 8-10% from last years’ meeting but that membership increased 15% from the previous year.
Errico’s speech to attendees solidified the changes in the focus of the organization that began two years ago under the leadership of former SAS President Karin Büttner-Janz, M.D. The fact that Errico spent the majority of his speech explaining what SAS stands for was a clear indication that the Spine Arthroplasty Society (the original name of the SAS), was now dead.
International Society for the Advancement of Spine Surgery
In its place?
“SAS is now the International Society for the Advancement of Spine Surgery, ” Errico told the audience in prepared remarks. “We still cover spinal arthroplasty, but we’ve expanded our scope to all surgical treatments that help spine patients.”
“SAS has always been international, but we really want to emphasize how quickly and effectively we are reaching around the globe.” There are now chapters in Korea, China, Taiwan, India, and the Middle East, and starting this June, in Latin America under the leadership of Brazil’s Luiz Pimenta, M.D.
“SAS is a society that deals only with innovative spinal technology, from occiput to pelvis, minimally invasive to maximally invasive, young to old, and degenerative to deformity. So SAS is the place where spine surgeons can discuss the things relevant to us and more importantly our patients, ” continued Errico.
Long live the ISASS er…SAS.
But a nagging question remains. Is there a need for a spine surgeon society when the North American Spine Society (NASS) is experiencing growing membership and influence with payers and regulators?
Errico, a former NASS president explained why surgeons need their own society after NASS made a strategic decision in the late 1990s and early 2000s to expand the organization.
“NASS holds a special place in my heart, they are our friend, ” said Errico. He said he remembers being the program chair for the annual NASS meeting in New York in the late 90s and reaching a critical mass of 1, 800 members. At that point the Society moved out of meetings in hotels and moved into convention centers.
He said he and his fellow NASS board members made the right decision to grow the organization. To accomplish that growth, NASS needed to reach beyond surgeons and include anyone dealing with the spine. That included rehab and pain management specialists, interventional radiologist and others.
“We were incredibly successful because there was a great need, ” said Errico. He says NASS now has over 5, 000 members and is no longer just a society for spine surgeons.
A Surgeon Society Gap
Errico believes there is a gap and a need for an international spine surgical society. “That’s the niche we are trying to carve out. We are in the process of an evolution.”
How will going global make it possible for SAS to advocate on public policy issues in different countries?
Errico says individual chapters in Korea, China, India, and Latin America will do that themselves while the larger organization will work in the U.S. and Europe.
We asked Errico if there a tension between advocating for surgery and other appropriate spinal care?
“No. It all starts with appropriate care for the patient. History is on the side of innovation that helps patients, ” he concluded.
“Does that mean every hiccup of an idea someone has is a good idea? No. That’s why SAS exists, to discuss those ideas.”
The Surgery Bias: Pro and Con
Errico says there is now an incredible amount of level-one clinical evidence. A few years ago spine surgeons were accused of being biased towards surgery without enough available evidence. That evidence now exists, but he believes payers and regulators still have a bias against surgery and continue to move the bar to approve new devices and pay for them.
“You can’t let your bias get in the way of prospective randomized studies.”
In an era of comparative effectiveness, Errico believes industry needs to fund societies to study existing technologies for their effectiveness. “I believe we are going to discover that surgery is the more cost-effective route [in many cases].”
“We will need to get rid of some of the existing technology that do not really work.”
This is where the tension will lie between various providers of spine care. With every innovation in a limited pool of resources, the existing technology must share the wealth.
As we’ve heard said in politics, “When the watering hole shrinks, the animals all start to look at other differently.”
Will some types of disc replacement be cheaper and better than fusion. “My intuition tells me that’s possible, says Errico. “This needs to be discovered without bias by either surgeons or payers.”
In his New Orleans speech, Errico said there are many things in spine surgery that remain poorly studied or lack consensus. Comparative effectiveness research could help resolve some of these uncertainties.
“Spine surgery is already far ahead of most other medical specialties in this game, because most of our best research has been comparative all along—we don’t really ever waste time and money studying placebos or waitlists in our clinical trials.”
Looking at arthroplasty for example, Errico says the early FDA trials were all comparative effectiveness research, because the comparison group—fusion—is an active real-world treatment that is routinely used. And now, he says the ongoing trials of Kineflex and Activ-L are even more purely comparative, because they compare one disc against another. “These studies may shed light more generally for all discs on the relevance of various disc design features.”
More research is needed to guide choices, not to eliminate them, added Errico. Increased promotion of research should benefit everyone by reducing uncertainty.
Improved Patient Selection
“We need new research to improve patient selection for some procedures. For example, among patients receiving fusion for degenerative disc disease, are there certain patient factors—age, smoking, Worker’s Comp, depression—that reliably predict lack of clinical improvement?
“We also need research to determine if some forms of treatment for a condition are better suited to specific subgroups of patients than others. For example, does kyphoplasty bring greater clinical benefit to certain subsets of vertebral fracture patients, such as the elderly or women, while vertebroplasty is better suited to other subsets of patients? These are questions we need to answer to better match the optimal treatments with the right patients.”
Industry/Surgeon Collaboration
In the old model of answering these questions, Errico says a company would come to surgeons and say, “Look, we’ve got this amazing new Spine-Widget, and we want you to do a study on it. You enroll the patients, we’ll provide the widgets; you do the surgeries, we’ll fund it.” But he acknowledges that the public is getting increasingly skeptical of these arrangements, due to perceived conflicts-of-interest.
A New Model
In the new model, Errico says a university department, private foundation, or professional society such as SAS will develop a portfolio of priority research themes that need to be addressed. Private donors, including industry, will contribute unrestricted sponsorship to this research program. Researchers will propose specific studies addressing the topics identified, and the foundation, university, or society will select specific studies to receive funding, based on peer review of the proposal merits.
“This model will create a buffer-wall against inappropriate influence while ensuring closer dialogue, and it will make precious data more widely available for the greater good of the entire spine surgery community, ” predicts Errico.
SAS Grows Up
Errico believes spine surgery is at a historic pivotal moment.
“Many breakthrough technologies are in the pipeline these days, and at the same time government is getting involved in healthcare like never before. We the spine surgery community need to proactively get research out there showing the benefits and value of our best available treatments.
“Medical companies have a crucial role to play in the R&D of the surgical technology we use to help our patients.”
He hopes that SAS will be the meeting place and mediator among spine surgeons from around the world and between surgeons and industry partners.
Will they come? Will a new mission and a new, yet undefined revamping of the annual meeting at the Venetian in Las Vegas next year, increase attendance and make exhibitors happy?
Will the new global SAS live long?
If Tom Errico is right and history is, as he says, on his side, then spine surgeons around the world who want to have their own venue, mission, and society will come and the answers will be yes.
Like a teen-ager inventing their way to adulthood, we’ll soon know what SAS looks like all grown up.
