Message from the Fellows Education Chairmen for DePuy Spine

Message from DePuy Spine Management Board

Clinical Forum

Surgeon Panel Case Discussion
Patient Case Presented by Dr. Nathan Lebwohl

The patient is a 13-and-a-half-year-old girl with a 46-degree single thoracic curve, with 7 degrees progression in the last 6 months. She is Risser 3, began her menses one and a half years ago. There is a family history of scoliosis. She has no neurologic abnormalities and no pain. She hates the way she looks, and clinically has a significant rotational abnormality with a prominent right rib hump. Her right shoulder is slightly elevated, and on forward bending she has more than 15 degrees of trunk rotation.

She was braced for two years, but admits to poor compliance.

Diagnoses:


Munish Gupta, MD
UC Davis Medical Center, Sacramento, CA

My approach would be posterior spinal fusion with a hybrid constrict. The fusion levels would be T4 to L1. I would use hooks above and wires in the middle and at least four screws on the bottom. I would also do a thoracoplasty to improve the cosmetic result and use the bone for bone graft. I do not normally use all screw constructs because the correction in such a case with the hybrid construct is quite good.


Kim Hammerburg, MD
Rush Medical College, Chicago, IL

The case presented appears to be a teenage girl with typical idiopathic adolescent scoliosis. The primary curve is a right thoracic curve with hypokyphosis. The radiographs have been labeled with 11 thoracic vertebrae and 5 lumbar. The right shoulder and neckline are mildly elevated on the standing postero-anterior radiograph. On side bending, the primary curve demonstrates significant correctability.

The high left thoracic and left lumbar curves are secondary, fractional curves. They demonstrate little or no rotation and do not cross the center sacral line. On side bending, they appear to be fully correctable. Because of these factors, I do not think that they need to be included in the instrumentation.

The preliminary levels of instrumentation of the primary right thoracic curve are determined by the standing PA and side bending radiographs. The final instrumentation levels are determined by the lateral radiograph because the end instrumented vertebrae should not be in a pathologic sagittal curve. Distally, L1 appears to be the vertebra with neutral rotation, but L2 appears to be the uppermost vertebra bisected by the center sacral line, or the stable vertebra. If the neutral vertebra and the stable vertebra are the same, the distal instrumented endpoint is easy to determine. In this case, I would select the neutral vertebra, L1, because of the correctability of the primary curve on side bending and the overcorrection of the lumbar curve on left side bending. I would anticipate almost full correction of the primary curve and therefore feel that it is safe to stop short of the stable vertebra. The sagittal contour at the thoracolumbar junction is normal in this case, so it is not a factor.

The upper instrumented vertebra must include all levels within the measured curve. In a primary right thoracic curve this is usually T4 or T5. The upper end vertebra should have neutral rotation and the disc space above it should demonstrate correctability to at least a position of parallel endplates on side bending. In this case, I would choose T4 as the proximal point of fixation. The proximal thoracic spine is often difficult to evaluate on lateral radiographs. If intra-operatively I found a segmental kyphosis between T4 and T3, I would extend the instrumentation to include T3.

I would plan a pedicle screw construct, but would have no reservations resorting to a hybrid construct of screws, hooks, and wires if obtaining an all screw construct proved difficult or unsafe. I try to achieve maximal fixation at the endpoints consisting of bilateral screws at the two adjacent proximal and distal levels. In this case bilateral polyaxial screws at T4 and T5, and T11 and L1. If I were to note a kyphotic transition between T4 and T3, I would extend the instrumentation with bilateral transverse process hooks at T3.

In general, I do not think that screws at every level are necessary, especially in a flexible adolescent curvature. I try to employ intermediary screws at strategic levels. I would instrument the concave side first. On the concave side of the spine, I identify the endpoints of the stiff section of the spine on side bending as suggested by Cotrel and Dubousset. In this case, I would implant reduction screws at T7 and T10 to translate the apical portion of the spine to the rod correcting both the scoliosis and hypokyphosis.

On the convex side, the apical vertebrae are T8 and T9. I employ uni-axial screws at these levels in an attempt to derotate the apical section of the curve. The rods are locked and secured proximally. Then, the translation of the concave apical section is done simultaneously with the derotation of the convex apical portion. These intermediate anchors are then locked. Finally, the distal anchors are locked in place. I have abandoned using cross links as they seem to be a recurrent source of irritation and discomfort, and I have not yet observed a problem related to their absence. Good correction and stability can be anticipated with this construct; T6 would be the only non-instrumented vertebra.

I would also perform a thoracoplasty in this adolescent girl who seems very concerned with her appearance. This procedure is done through the same mid-line incision by elevating the superficial musculature of the back. I generally resect the apical five ribs from just medial to the costal angle to the tip of the transverse process, which can be resected as well in large deformities. By resecting the rib medial to the costal angle, the rib has a natural ventral curve, which avoids having the pointed ends of the ribs sticking up. At one time I disarticulated the rib heads but found this caused more bleeding and increased the need for a chest tube. I try to avoid resecting the last full rib because when taken it allows the lateral border of the chest to collapse in, creating a deformity almost as bad as the rib prominence. The ribs provide an excellent source of autograft for the fusion, which is still my preference.


Baron Lonner, MD
New York Hospital for Joint Diseases New York, NY

This patient represents a common presentation of AIS. Single overhang structural thoracic curves comprise approximately 50% or more of cases.

This patient has had progression of curvature despite bracing. She was not compliant with her brace, which in my experience is not uncommon. Curve progression of approximately one degree per month is not excessive. If a greater rate of curve progression was found, one should consider MRI screening of the spinal canal from the occiput to the sacrum to rule out anomalies such as syrinx or tethered cord that may have lead to the rapid progression and would require treatment prior to consideration of corrective surgery of the deformity. One should do a thorough neurological evaluation including gait evaluation, motor, sensory, and reflex evaluation including abdominal reflexes and Babinski reflexes. Subtle deficits may be expressed clinically by findings such as calf or thigh asymmetry, cavus foot, or curled toes. Assuming all is normal, it is reasonable to consider surgical correction without further evaluation.

Surgical indications in the adolescent patient with idiopathic scoliosis include curve progression over 40 degrees in a skeletally immature patient, progression despite bracing, and curve magnitude of 50 degrees or more in a skeletally mature patient.

The magnitude of clinical deformity as represented by the angle of trunk rotation, and shoulder and waist asymmetry plays a role in determining appropriateness of surgery particularly in the skeletally mature patient. In this case one could approach this curvature from an anterior approach, either open or via a video-assisted thoracoscopic (VATS) technique or a posterior approach. In this case, the thoracic spine is hypokyphotic. In the absence of pulmonary decline pre-operatively the reason to improve kyphosis may be to preserve junctional regions adjacent to the spinal fusion years down the line. This remains to be studied. Anterior approaches appear to improve kyphosis better than posterior surgery with current techniques. However, the anterior approach has the disadvantage of temporarily diminishing pulmonary function. This is mitigated by the VATS approach. The VATS technique is best limited to 7 segments or less and to the levels of T5-12 for technical reasons and for purposes of operating efficiency. Thus, I would tend to do this from a posterior approach. New ultrastrength rods may influence the surgeons’ ability to restore kyphosis compared to standard rods. Alternatively, larger diameter (6.35mm) rods may be beneficial in this regard.

I would perform a posterior fusion with segmental pedicle screw fixation at each level of the concavity and the two cephalad and caudad levels of the convexity and three or four apical levels on the convexity of the curvature. I would utilize polyaxial screws at the two proximal and two distal vertebrae within the fusion and uniplanar screws at all other levels instrumented to facilitate direct vertebral derotation maneuvers. In addition, apical distraction on the concave rod as well as in-situ contouring may facilitate improvement of the thoracic kyphosis. I would include T4 proximally and L1 distally as this is touched by the center sacral vertical line and the lumbar curvature corrects completely on side-bending. One must pay attention to proximal thoracic kyphosis to avoid junctional kyphosis. In this case, the proximal thoracic spine is minimally kyphotic. I utilize cancellous allograft in these patients and allow return to sports activities beginning at approximately three months postoperatively.


Harry Shufflebarger, MD
Miami Children Children's Hospital, Miami, FL.

This is Lenke 1A, probably minus. Prof Suk would classify this as type 1, probably subgroup 1 and not 2.

As noted, there are 11 vertebra with ribs, thus T1-T11 and L1-L5. The important things for me to look for are neutral vertebra distally and which vertebra(e) are touched by the CSL.

The film quality is not good enough in the reproduction to state for sure what vertebra is neutral.

L1 appears neutral, and is touched by CSL (barely). End of Cobb is T11, which is not touched by CSL. Because of these factors, I would select L1 as the distal end of instrumentation.

T4 is one proximal to the end of Cobb, and I would choose T4 as the proximal end vertebra.

I would use bilateral pedicle screws at every level.

Ask the Expert

DC: Clinical data are extremely important. The questions that come to mind when evaluating a new device/technology are: What are the indications for the device and what type of clinical data to support its use are available? Level 1 prospective randomized data are more scientific and most important when new technologies are being evaluated. I rely on prospective randomized data, as well as cost-effectiveness, to assess whether or not a device will be applicable to my practice. Clinical data, especially Level 1 data, allows you to compare something you know like fusion and analyze the areas of relative weaknesses and strengths of a new technology. Take CMS’ ruling on Lumbar Artificial Disc replacement: Data evaluation is necessary because, as a clinician, you don’t consider one technology better than another in a void. The pertinent question to the clinician is, in a specific patient will this new technology offer a better potential outcome? Considering all viable options for your patients makes you a better surgeon. Spine surgery is not “cookie cutter” medicine.

Level II and III data can also be useful in evaluating new technologies. For example, Thierry David, MD has recently published his results of long-term follow-up on his large series of patients treated with lumbar total disc replacement (Long-term results of one-level lumbar arthroplasty: Minimum 10-year follow-up of the CHARITÉartificial disc in 106 patients. Spine 32 : 661-666, 2007). This European experience is longer than in the US and allows us to evaluate the long-term potential of this relatively new technology.

DC: Data collection is important to clinicians. Good quality data allows the clinician to determine if a product is safe and efficacious in the short-term. Once a device is deemed to have equal safety and efficacy in the short-term compared to a standard, the clinician can decide if the potential long-term benefits in a particular patient justify its use. The clinician should be making that decision. Using total disc replacement as an example, once the device is shown to be as safe and efficacious as the standard (i.e., fusion) in the short-term, it should be up to the clinician to decide if the potential long-term benefits of maintenance of motion and decreased adjacent level stresses justify its use in a particular patient.

The Centers of Arthroplasty Excellence in Spine (CARES) Patient Registry is a good way to collect data on a relatively new technology. The Level I IDE data show that total disc replacement devices are safe and efficacious in the short-term. The CARES data set has the potential to prove the intermediate- and long-term benefits of motion preservation, most notably a decrease in symptomatic adjacent level degeneration.

DC: Biomechanics are critically important in arthroplasty. When comparing an unconstrained device with a mobile core (CHARITÉ Artificial Disc) to a device with a fixed core (PRO-DISC-L)the question is not which one is inherently better but which one will best treat a specific patient’s spine pathology.

An unconstrained device with a mobile core unloads the facets and most closely mimics normal anatomy as determined by an article written by Missoum Moumene, PhD and Fred Geisler, MD, PhD recently published in Spine (for a complete copy of this article please see the DePuy Spine in the Journals section of this newsletter), entitled Comparison of Biomechanical Function at Ideal and Varied Surgical Placement for Two Lumbar Artificial Disc Implant Designs: Mobile-Core Versus Fixed-Core. This Finite Element Analysis (FEA) study concludes that a mobile-core artificial disc design is less sensitive to placement and unloads the facet joints, compared with a fixed-core design. [Note: A Finite Element Analysis is an engineering computer simulation based on mathematics.] Therefore an unconstrained core device may be advantageous when dealing with a particular patient with mechanical low back pain and relatively isolated degenerative disc disease and otherwise normal spine biomechanics. Conversely, a patient with altered biomechanics, such as a loss of sagittal balance with mild kyphosis, may benefit from a fixed-core device.

It is of critical importance to determine the specific pathology you hope to address in a particular patient and let knowledge drive your decision in determining which type of device to use.

DC: You always want to know what your revision strategy will be when performing any spine surgery. When performing an anterior retroperitoneal approach for total disc replacement, it is especially important to consider revision options. Generally, your first salvage option is to fixate and fuse posteriorly. But if there has been migration or significant subsidence, then a re-do anterior or lateral approach may be indicated. In my experience, tooth-based fixation devices are easier to revise compared to keel-based devices. Last week, I performed a revision of a CHARITÉ disc that had been placed in Europe. I was able to remove the device and perform an interbody fusion with lateral plate fixation through a lateral, trans-psoas, minimally invasive approach. With a keel-based device, I would have had to take a more extensive transperitoneal approach and perform a partial corpectomy.

Practice Related Nuances

Top Ten Things to Seek in Your First Job
Jamie Stuart, JD

There are of course more than ten things to seek in your first job, but if you get satisfactory answers to the following list, it may prevent you from leaving in search of a second job!

10) An orderly and consistent Retirement Policy . Especially for a sizeable group, having a clear and reasonable retirement protocol is important to you, since it is you (and the other remaining surgeons) who will be funding these accounts. Optimally, you want to see the following:

• Even-age differential among your partners to eliminate a bunching of two or more retirements within a few years.
• A sensible buy-out price formula (compatible with the buy-in pricing), e.g., book value of the practice’s hard assets plus the retiree’s trailing receivables paid as collected.
• A workable “pull-back” policy to give incentive to senior surgeons to continue working enough hours to facilitate bearing their pro-rata overhead burden. Or, in the alternative, an agreement to retire by a specific date in the near future, so the group can recruit a replacement in a timely manner.

Avoid Billing Black Holes: Ensure All Surgeries are Billed
Jennifer Bever

Whether you are a resident in training or a surgeon in practice, there is a need to ensure that all surgical services have been recorded, submitted, and billed. Residents are often delegated the responsibility of dictating operative notes for attending physicians, which may trigger the billing cycle in an academic institution. What happens after that may be a mystery to many, but it doesn’t have to be. Private practice physicians may be required to circle or list procedures for the billing team, but after a weekend on call they can’t quite remember if they turned in those all-important billing sheets or not.

There are several things one can do to help ensure all services are accounted for. Some practices provide physicians a list of all billed surgeries…and payments received. Here’s how to make this a reality in your practice or department:

• First, all elective cases should be scheduled/recorded in the practice or department billing system. If they are, a report can be generated from the system each day or at least once a week to show scheduled services where no charges have been received and entered. This report is the first fail-safe to review and ensure planned services are billed.
• Secondly, because dictation is in clinical lingo and CPT has its own lingo, it is helpful if physicians with coding knowledge list their procedures on a billing sheet and submit to billing. The team can certainly review the operative note for additional information, and request an addendum if the operative note does not clearly define separate procedures, unusually difficult case circumstances, etc. Submitting codes ensures the billing team starts the billing process as soon as possible, which in turn promotes timely payment.
• The billing sheet becomes key as a method to signal non-elective or emergent services. Because these services weren’t scheduled, they won’t appear on the computer reconciliation report discussed above. It is critical the surgeon signal such services and start the billing process.
• Ideally, however, billing departments won’t rely completely on physicians’ turning in billing sheets. Many hospitals now offer access to their systems and/or OR case logs which should be used as a cross check that all services have been recorded and billed. The online access to hospital census data is also quite helpful as a check that all hospital consults performed by the physician have been submitted and billed.
• Lastly, some billing departments provide surgeons with a list of all surgeries received and billed for the month. Many surgeons can scan patient names and ask questions about “where is Mrs. Jones’ surgery?” or “why didn’t Mr. Smith’s case show up this month?” Or take this one step further and keep a running Excel spreadsheet of surgeries billed and their payment amounts. Again, coding and reimbursement savvy physicians can then spot-check and ask questions about non-payments, recognition of modifiers, etc.

The preceding articles were provided by KarenZupko & Associates, a physician practice management consulting and educational firm working for and with surgeons since 1985.

DePuy Spine does not endorse or recommend practice management firms. Physicians should research practice management consulting options before choosing one to work with.

The appearance of job opportunities in this newsletter in no way serves as an endorsement of the opportunity, the practice, or the surgeons thereof, by DePuy Spine. These opportunities are included as a courtesy to the practice and a service to the target audience of this newsletter. DePuy Spine reserves the right to reject any or all future submissions for any reason.

Physician group practice seeks 2 BC/BE Neurosurgeons to join 3 BC Neurosurgeons and a BC Orthopaedic Spine surgeon. Each surgeon has a dedicated PA and MA.

This practice opportunity offers it all: first-year income guarantee plus productivity bonus; a call schedule of 1/4 and state-of-the-art office with electronic patient medical records and remote access to radiology images. The office is conveniently located adjacent to the hospital.

The opportunity also includes recruitment incentives and two-year track to partnership. Full benefits package, including vacation, CME, and retirement plan.

Community
Live and work in a scenic, mid-size city nestled in a unique valley rich with historic traditions. A culturally diverse community, offering all the amenities expected to be found in a large metropolitan city. Whether you enjoy fine dining and symphony orchestras or challenging golf courses, mountain biking, snow skiing, or white water rafting, this outstanding community offers something for everyone. The climate is exemplary and residents enjoy four distinct seasons. The education system is outstanding offering both public and private schools, making it an ideal location to establish roots and raise a family.

Facility
Charleston Area Medical Center (CAMC) is West Virginia's largest medical center with 913 licensed beds, which includes one of two Level I Trauma Centers in the state. CAMC is affiliated with West Virginia University Charleston Division. Residents, medical students, and allied health students preceptor at all three of our facilities. A full range of multi-specialty physician support as well as excellent rehabilitation therapy, complement our high quality of care.

For more information
For more information about this opportunity contact Diana Williamson, CPA, Administrator at (304) 344-3551 or (304) 344-5005. You can also email your CV to diana@wvneuro.com or visit Neurological Associates, Inc.'s website at www.wvneuro.com.

Spine Trained Surgeon Needed in Long Beach, CA, Area

This practice seeks a spine surgeon to perform general orthopaedic spine surgery procedures. Surgical cases will take place primarily at St. Mary’s Hospital, Long Beach, CA.

Contact:
Corinne Walker, Office Manager
1040 Elm Ave., Suite 100 Long Beach, CA 90813
Office (562) 591-4444, x108
Fax (562) 432-0656

A Look Back – Second Quarter Educational Events Highlights

A Look Ahead – Upcoming Education / Events

Must Read Clinical Articles – Suggestions from the Fellows Education Chairmen

To obtain a free copy of these articles simply click on the link below.

A Practical Guide to Assigning Levels of Evidence, James G. Wright, J. Bone Joint Surg. Am. 2007;89:1128-1130

Read Article...


Diabetes and Early Postoperative Outcomes Following Lumbar Fusion, Browne, et al. SPINE (32):20, 2214-2219, 2007.

Read Article...


A Pedicle Screw Construct Gives an Enhanced Posterior Correction of Adolescent Idiopathic Scoliosis When Compared with Other Constructs, Vora, et al. SPINE (32):17, 1869-1874, 2007

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.

Prevalence of Heterotopic Ossification Following Total Disc Replacement: A Prospective, Randomized Study of Two Hundred and Seventy-six patients. Tortolani, et al. The Journal of Bone and Joint Surgery. 89(1): 82-88, January 2007.

Read Article...


Is One Cage Enough in Posterior Lumbar Interbody Fusion: A Comparison of Unilateral Single Cage Interbody Fusion to Bilateral Cage. Fogel, et al. J. Spinal Disorder Tech 2007;20:60-65. 

Read Article...


Comparison of Biomechanical Function at Ideal and Varied Surgical Placement for Two Lumbar Artificial Disc Implant Designs: Mobile-core versus Fixed-Core. SPINE; 32(17): 1840-1851, 2007

Read Article...

DePuy Spine 2nd Annual Clinical Research Paper Challenge

The 2nd Annual DePuy Spine Clinical Research Paper Challenge is underway. 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.

Each year, 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.

The deadline for abstract submission has passed (November 19, 2007). All those who submitted an abstract should have received notification of approval from DePuy Spine, indicating that proposals were received, reviewed, and abide by the rules of the Challenge, by December 5, 2007.

If you need more information or have any questions, please contact Jim Giuffre in the DePuy Spine Medical Education department by email or at (508) 828-2825.

Spine Case Challenge #3

A. Spinal stenosis with neurogenic claudication.
B. Lumbar disc herniation with radiculopathy.
C. Lumbar synovial cyst with radiculopathy.
D. Ependymoma with radiculopathy.
E. Degenerative scoliosis with foraminal stenosis and radiculopathy.

A. Epidural steroids including interlaminar or transforaminal injections.
B. Laminotomy with lateral recess decompression and lesion excision.
C. Microdiscectomy.
D. Fusion with scoliosis correction.

A. Postoperative instability and recurrent radiculopathy.
B. Adjacent segment degeneration.
C. Lesion recurrence.
D. All of the above.

Winners of Spine Case Challenge #2

Thank you to all who participated in the 2^d 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:

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.

1). What is the diagnosis?

A. Congenital deformity
B. Unilateral facet dislocation
C. Bilateral facet dislocation
D. Bilateral perched facets

2).  What is the most appropriate first step in management in the emergency department?

A. Halo application
B. MRI
C. Closed reduction with fluoroscopy
D. Flexion and Extension radiographs

3) Further management of this injury should consist of?

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

And the winners are…………..

Dennis Cramer, MD, Colton, CA
Patrick Hsieh, MD, Baltimore, MD
Todd Jackman, MD, University of Minnesota
Yuri Falkinstein, MD, San Francisco, CA

Next Quarter...

• Looking for a job? The top 10 things you need to know
• Surgeon panel case discussion
• What’s in my bag? Surgeon interview
• How can you differentiate your practice?
• And more...