Vertebral Columns, Spring 2021 by International Society for the Advancement of Spine Surgery

INSIDE

Prone Lateral Surgery: Why Do It? Is It Worth It? SPECT/CT and Pain Generators in the Spine: Hype or Evidence Based? Comparison of Perioperative Outcomes Between Awake Versus Conventional Minimally Invasive Transforaminal Lumbar Interbody Fusion Why All Physicians Should Go Out of Network—And Why They Probably Won’t

Vertebral

COLUMNS International Society for the Advancement of Spine Surgery

SUCCESSFUL IMPLEMENTATION OF SOCIAL MEDIA FOR SPINE PRACTICE

SPRING 2021

Does Intraoperative Neuromonitoring Prevent Neurologic Injury in Spine Surgery?

Editor in Chief Kern Singh, MD

3 8 11 14 17

EDITORIAL Successful Implementation of Social Media for Spine Practice

CLINICAL PRACTICE Does Intraoperative Neuromonitoring Prevent Neurologic Injury in Spine Surgery?

CLINICAL PRACTICE Prone Lateral Surgery: Why Do It? Is It Worth It?

TECHNOLOGY SPECT/CT and Pain Generators in the Spine: Hype or Evidence Based?

Managing Editor Audrey Lusher Designer CavedwellerStudio.com

PATIENT OUTCOMES Comparison of Perioperative Outcomes Between Awake Versus Conventional Minimally Invasive Transforaminal Lumbar Interbody Fusion

PAYMENT MODELS Why All Physicians Should Go Out of Network—And Why They Probably Won’t

Become a member today https://www.isass.org/about/membership/

Spring 2021

Editorial Board Peter Derman, MD, MBA Brandon Hirsch, MD Sravisht Iyer, MD Safdar Khan, MD Yu-Po Lee, MD Sheeraz Qureshi, MD Grant Shifflett, MD

Vertebral Columns

Vertebral Columns is published quarterly by the International Society for the Advancement of Spine Surgery. ©2021 ISASS. All rights reserved. Opinions of authors and editors do not necessarily reflect positions taken by the Society. This publication is available digitally at www.isass.org/news/vertebralcolumns-Spring-2021

isass.org

From the Department of Orthopaedic Surgery at Rush University Medical Center in Chicago, Illinois.

EDITORIAL

Successful Implementation of Social Media for Spine Practice The means by which we maintain communication with classmates, friends, and family has drastically evolved over the past 2 decades to become a pervasive part of the modern experience. This evolution of communication has been primarily driven by the creation of the “Web 2.0,” more commonly known as social media. What initially began as tools to maintain relationships, social media is now an important venue for dissemination of information and acts as an effective marketing platform for medical practices. Breaking into the world of social media in a professional context may be daunting to some surgeons; however, for those who are able to effectively navigate the “social network,” a strong online presence may have substantial benefits. An ever-increasing number of social media platforms exist, though several dominant players have clearly emerged. The choice of which platform to use is dependent upon the individual physician’s goals and personal preferences.

Establishing Clear Professional Goals The first step for effective use of social media by any physician should be to clearly define and conceptualize what he or she hopes to accomplish through their online presence. An envisioned goal may be as simple as a younger attending surgeon looking to expand his or her practice by increasing their

isass.org

visibility and name recognition. For others, social media may act as a venue for spreading important medical information and sharing new research findings. Physicians could also consider its use as an effective networking tool to help build professional relationships with colleagues. While adaptable for each individual’s goals, Facebook, Twitter, and Instagram are best used for general purposes and are among the most popular platforms.1 More professional and business-oriented applications may be best served through LinkedIn and ResearchGate, though more traditional platforms may meet these needs as well.

Conor P. Lynch, MS

Elliot D.K. Cha, MS

Kern Singh, MD

Expanding Practice and Professional Profile Just as surgical techniques have evolved over the past decade, so too have marketing strategies to expand a physician’s practice. While referrals and word of mouth still generate a large portion of a physician’s practice, surgeons looking to modernize their outreach should consider that nearly 80% of adult internet users have used some form of an online resource to better understand health information.2 This

Vertebral Columns

Spring 2021

EDITORIAL

may translate into an estimated 6.5 million health-related searches on any given day. 3 Physicians clearly stand to benefit from the use of social media platforms to attract new patients; however, use of the various marketing outlets should be conducted in a goal-oriented manner to optimize the chances of gaining new business. Commercials, printed media, or billboards may attract an older demographic, but a younger cohort may perceive such methods as antiquated and ineffective. Platforms such as Facebook and, more so, Instagram have become better tools to reach a younger demographic. If the practice’s goal is aimed at growing through professional networks, providers should consider LinkedIn or other job-related sites. Social media gives many physicians the opportunity to have significant autonomy with regard to the content and style

Social Media Terms Defined • Social media: Forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other media content • Social network: An online service or dedicated website through which people create and maintain interpersonal or business relationships • Tweet: A post made on the Twitter online message service • Retweet: To share or “repost” a tweet previously made by another user to the Twitter online message service • Engagement: Measure of public shares, likes, and comments for an online entity’s social media efforts • Mention: When a brand is referenced, or “mentioned,” online, particularly on social media sites Sources: Definitions adapted from Meriam-Webster Online Dictionary (https://www.merriam-webster.com) and BigCommerce (https://www. bigcommerce.com).

Spring 2021

Vertebral Columns

of the material they promote, therefore care must be taken to maintain an online persona of a trusted healthcare provider. Whichever strategy a physician opts to use, the efficacy of social media to expand one’s practice is undeniable. Donally et al4 demonstrated that physicians with an active presence on Facebook averaged higher ratings on Healthgrades.com and Google.com, whereas those who were active on Instagram had higher ratings on Vitals.com. Others have also suggested that a snowball effect occurs with positive posts, whereby a single post may generate up to 12 subsequent posts, all of which correlates with an increase in bookings.5

Public Education and Dissemination of Research In addition to increasing the visibility of a spine practice, social media can also provide an excellent opportunity for patient engagement in an informational and educational capacity. Use of Facebook Live grants physicians a unique interaction with current and prospective patients by using real-time video streaming sessions to directly address health-related questions and comments. However, a caveat with successful use of this outlet is the small room for error. Misconstrued messages or poor delivery of a message can negatively affect one’s online presence. A potentially safer avenue is through Twitter, which many medical professionals find to be an effective medium for sharing health-related information. With a limit of 280 characters for each post, or “tweet,” Twitter promotes concise, easily digestible information that can be readily shared or “retweeted” among numerous users.

isass.org

EDITORIAL

For many, the purpose of using social media may be to disseminate appropriate medical knowledge pertaining to the field of spine surgery and dispel any myths or correct misinformation. However, physicians may also use social media to help introduce newer technology such as endoscopic and robotic surgery and even assuage fear or skepticism surrounding topics such as ambulatory surgical centers or awake spine surgery. Additionally, social media may represent a unique venue for dissemination of academic research. In their study “The Top 100 Spine Articles on Social Media,” Parrish et al6 found that the articles receiving the most attention on social media differ significantly from those that are most frequently cited in the scientific literature.

Networking With Colleagues While social media can offer numerous opportunities to engage with patients and members of the general public, it may also offer opportunities to strengthen one’s professional network and collaborate with contemporaries in one’s field, both domestically and internationally. LinkedIn can serve as an effective hub for managing one’s professional presence online. It provides a clearly organized summary of an individual’s academic and professional background, current work-related interests, and, unlike Facebook or Instagram, seeks to create a network of individuals specifically with professional connection in mind. With a purpose even more focused than LinkedIn, ResearchGate allows physicians/ researchers to track and disseminate academic research. In addition to helping one keep up with colleagues’ newest work,

isass.org

ResearchGate allows individuals to easily share or recommend work they feel is particularly impactful or beneficial for others to read. However, more “traditional” social media platforms may also be effective for dissemination of current research. Parrish et al6 demonstrated that Twitter was by far the largest source of “mentions” for research articles, contributing approximately 8,000 to 10,000 annual mentions over the past 5 years. Additionally, for many surgeons, academic conferences serve as a means to stay in touch with their contemporaries and keep up to date on the newest developments in their field. Social media such as Linkedin and Twitter may offer an excellent opportunity to plan, share, and receive information regarding such conferences.

Potential Pitfalls In spite of its many benefits, several ethical, legal, and professional factors should be considered when integrating social media into a spine practice. Physicians have a responsibility to disseminate medical information that is not only high quality but also empowers individuals to make informed decisions. With online orthopedic literature demonstrating large variability in quality and low readability,7-10 physicians may mitigate these issues by providing accurate yet usable information for patients. The liability of a physician’s social media presence is still not well established; however, use of any patient health information can still fall under the statutes laid out by the Health Insurance Portability and Accountability Act or Health Information Technology for Economic

Vertebral Columns

Spring 2021

EDITORIAL

and Clinical Health Act. Patients may take to social media in pursuit of medical advice specific to their condition that would really only be appropriate to render in a private, controlled setting (ie, in the clinic or during a telemedicine visit). Although formal regulations are unclear, once a more personalized line of communication is established through social media outlets, it could be construed as eligible for malpractice liability. Additionally, the degree of time commitment will largely affect the production of social media content. Other physicians have reported that a successful online presence may require a maximum of 30 minutes per day,11 which may or may not be feasible for a given physician. However, this time commitment is largely dependent on familiarity with each type of outlet and is predicated on having an abundance of newsworthy content. For some, institutional marketing teams may help generate strategies and content to reduce the time

required to maintain a healthy social media presence, but physicians should be cautioned against surrendering too much creative power to these teams. While this practice may allow for a more active profile or a greater quantity of “engagements,” it may limit the ability to provide valuable insight or could raise ethical issues if patients believe they are interacting with a physician but posts are actually made by administrative staff.

Moving Forward Physicians looking to add social media to their practice may find that the benefits outweigh many of the obstacles and drawbacks. Older and more traditional modes of marketing may still help grow or sustain a practice, but with current and future patients and professionals increasingly adopting the use of online platforms, spine surgeons will stand to benefit from integration of social media into their career goals. n

References 1. Statista. Most popular social networks worldwide as of January 2021, ranked by number of active users. https://www. statista.com/statistics/272014/globalsocial-networks-ranked-by-number-ofusers/. Accessed March 28, 2021. 2. Fox S. The social life of health information, 2011. Pew ResearchCenter. https://www.pewresearch.org/internet/2011/05/12/the-social-life-of-healthinformation-2011/. Published May 12, 2011. Accessed March 28, 2021. 3. McLawhorn AS, De Martino I, Fehring KA, Sculco PK. Social media and your practice: navigating the surgeon-patient relationship. Curr Rev Musculoskelet Med. 2016;9(4):487-495. 4. Donnally CJ 3rd, McCormick JR, Pastore MA, et al. Social media pres-

Spring 2021

Vertebral Columns

ence correlated with improved online review scores for spine surgeons. World Neurosurg. 2020;141:e18-e25. 5. Camp SM, Mills DC 2nd. The marriage of plastic surgery and social media: a relationship to last a lifetime. Aesthet Surg J. 2012;32(3):349-351. 6. Parrish JM, Jenkins NW, Brundage TS, Hrynewycz NM, Singh K. The top 100 spine surgery articles on social media: an Altmetric study. Spine. 2020;45(17):1229-1238. 7. Long WW, Modi KD, Haws BE, et al. Assessing online patient education readability for spine surgery procedures. Clin Spine Surg. 2018;31(2):E146-E151. 8. Eltorai AEM. Cheatham M, Naqvi SS, et al. Is the readability of spine-related

patient education material improving? An assessment of subspecialty websites. Spine. 2016;41(12):1041-1048. 9. Fabricant PD, Dy CJ, Patel RM, Blanco JS, Doyle SM. Internet search term affects the quality and accuracy of online information about developmental hip dysplasia. J Pediatr Orthop. 2013;33(4):361-365. 10. Dy CJ, Taylor SA, Patel RM, Kitay A, Roberts TR, Daluiski A. The effect of search term on the quality and accuracy of online information regarding distal radius fractures. J Hand Surg Am. 2012;37(9):1881-1887. 11. Social media for orthopaedic surgeons. AAOS Now. October 2010. https:// www.aaos.org/AAOSNow/2010/Oct/ youraaos/youraaos11/?ssopc=1. Accessed March 28, 2021.

isass.org

CLINICAL PRACTICE

From Northwell Health in Long Island, New York (Dr. Kiridly), and the Texas Back Institute in Frisco, Texas (Drs. Satin and Derman).

Does Intraoperative Neuromonitoring Prevent Neurologic Injury in Spine Surgery?

Daniel Kiridly, MD, MBA

Alexander Satin, MD

Peter Derman, MD, MBA

Intraoperative neuromonitoring (IONM) has been utilized in spine surgery since the 1970s to assess the integrity of the spinal cord and peripheral nerves in real time. It was first widely adopted in adult and pediatric spinal deformity surgery in response to the relatively higher risk of neurologic injury during these procedures. IONM has become increasingly prevalent over the past 20 years in the United States as its use has extended to an increasing array of spinal procedures.1 Nonetheless, there remains large geographic variations in IONM utilization.1,2 Given the increasing cost burden associated with widespread IONM use, we review the literature to determine the extent to which IONM prevents neurologic injury and thereby delivers value to patients.

IONM Is Accurate in Detecting Neurologic Deficits There is a large body of scientific evidence investigating whether significant changes in IONM signals predict postoperative neurologic deficits. Studies assessing the accuracy of IONM

Spring 2021

Vertebral Columns

typically report its sensitivity and specificity by comparing the presence of significantly decreased signals at the end of the case to the gold standard of postoperative neurologic examination. Older studies (performed during the era of isolated somatosensory evoked potential [SSEP] monitoring) tended to demonstrate unacceptably high rates of false positives and low specificity. For instance, a 1996 review of 183 consecutive cervical cases with SSEP monitoring alone reported a sensitivity of 99% but a specificity of 25%.3 The subsequent addition of motor evoked potentials (MEPs) and the development of multimodal IONM (MIONM) protocols (ie, IONM utilizing SSEPs, MEPs, and spontaneous electromyography) significantly increased IONM accuracy. In 2015, Bhagat et al4 examined 354 consecutive deformity cases using MIONM and found a sensitivity of 100% and a specificity of 99.3% for the detection of postoperative neurologic deficits. Additionally, Eggspeuhler et al5 examined MIONM for 246 consecutive cervical spine operations in 2007 and reported 232 true negatives, 2 false negatives, 10 true positives, and 2 false positives, resulting in a sensitivity of 83.3% and a specificity of 99.2%. Sutter et al 6 also examined the efficacy of MIONM in 409 selected cases of lumbosacral decompression with and without fusion and

isass.org

CLINICAL PRACTICE

observed a sensitivity of 90% and a specificity of 99.7%. Taking these studies together, there is strong and consistent evidence that MIONM is accurate in its ability to predict postoperative neurologic deficits across a wide array of spine procedures.

But Is IONM Neuroprotective? Given that IONM is an accurate predictor of postoperative neurologic deficits, it seems to follow logically that the feedback it provides would allow the surgical team to address impending neurologic injury while it is still reversible. This is not necessarily true, however. It is possible that some IONM alerts arise from neurologic injury that is no longer reversible by the time it is detected. Furthermore, intraoperative causes of neurologic injury (eg, hypotension or misplaced hardware) might be detected by other means and corrected regardless of the presence of IONM. For IONM to truly be neuroprotective, it would have to expeditiously identify reversible causes of neurologic injury that would have otherwise been missed by other means. Definitive proof of neuroprotection would require demonstrably lower rates of neurologic injury in identical patient cohorts with and without IONM use. The evidence that IONM prevents neurologic injury is more limited relative to that demonstrating its accuracy. Older studies attempted to compare monitored and unmonitored cohorts using historical controls before and after the adoption of IONM. In a 1993 study, Epstein et al7 used a historical cohort to retrospectively compare 100 patients who underwent scoliosis surgery with SSEPs to 218 patients who did not. They reported a 3.7% rate of quadriplegia

isass.org

in the unmonitored cohort with no postoperative deficits in the monitored cohort.7 In 1988, Meyer et al8 compared 145 patients who underwent surgery for thoracic or lumbar trauma with SSEPs to a historical cohort of 150 unmonitored patients. The authors observed a rate of 0.7% for new deficits in the monitored group and 6.9% for deficits in the unmonitored group.8 Although these earlier studies appear to suggest that IONM is neuroprotective, there are limitations to studies utilizing historical surgical cohorts—namely, surgical techniques improve and evolve over time, thus introducing a potentially confounding variable. More recent studies with better-matched control groups have painted a different picture. A 2007 study by Smith et al9 compared 577 patients who underwent anterior cervical discectomy and fusion (ACDF) with IONM to 462 patients who did not. Authors reported no new postoperative neurologic deficits in the unmonitored group. In the monitored group, one patient awoke with partial central cord syndrome despite an absence of alerts on IONM. They concluded that the use of IONM does not impact neurologic injury rates in ACDF.9 In 2014, Cole et al2 used data from a US

Terminology • Somatosensory evoked potentials (SSEPs) measure the amplitude and latency of retrograde signals arising from peripheral nerve stimulation. They are effective in monitoring the dorsal columns of the spinal cord but do not provide information about the anterior motor pathways. • Motor evoked potentials (MEPs) measure skeletal muscle action potentials arising in response to transcranial electrode stimulation, giving data on the integrity of the anterior and lateral corticospinal tracts. • Spontaneous electromyography (EMG) monitoring is performed via the same muscle leads that receive MEP responses. It provides real-time information about the direct stimulation of neural elements during surgery.

Vertebral Columns

Spring 2021

CLINICAL PRACTICE

national database to assess the incidence of 30-day neurologic complications in all types of single-level spine surgeries. While there was a correlation between IONM use and decreased neurologic complications in lumbar laminectomies (0.0% vs 1.18%, P=0.002), there was no significant difference with IONM in the setting of lumbar discectomy, lumbar fusion, or ACDF.2 Ajiboye et al1 used another nationwide database to investigate trends in the utilization of IONM during scoliosis surgery from 2005 to 2011 in the United States. IONM was used in 37.6% of the 3,618 scoliosis surgeries identified, but there was no significant difference in neurologic injury rates with or without IONM (1.8% and 2.0%, respectively, P=0.561).1 However, the results of these database studies should be interpreted with caution, as patient cohorts may differ in relevant characteristics, which were not identified in the different data sets.

Conclusion Current evidence suggests that IONM signal

changes are reasonable predictors of whether patients will suffer postoperative neurologic deficits. However, it remains unclear whether IONM actually prevents neurologic injury. Older studies with historical cohorts tend to demonstrate lower rates of neurologic injury with IONM use. More recent national database studies instead suggest that IONM has no bearing on postoperative neurologic status for most types of operations. Unfortunately, there are significant methodological flaws with the existing studies, and no prospective randomized trials on IONM use in spine surgery have been performed to date. Despite the lack of definitive evidence supporting the protective effect of IONM, its use continues to rise, as do associated costs to the health care system. Medicolegal concerns and possible financial conflicts of interest may contribute to this trend. If such expenditures are to be justified, high quality studies are needed to establish whether IONM confers clinical benefit. n

References 1. Ajiboye RM, Park HY, Cohen JR, et al. Demographic trends in the use of intraoperative neuromonitoring for scoliosis surgery in the United States. Int J Spine Surg. 2018;12(3):393-398.

4. Bhagat S, Durst A, Grover H, et al. An evaluation of multimodal spinal cord monitoring in scoliosis surgery: a single centre experience of 354 operations. Eur Spine J. 2015;24(7):1399-1407.

7. Epstein NE, Danto J, Nardi D. Evaluation of intraoperative somatosensory-evoked potential monitoring during 100 cervical operations. Spine (Phila Pa 1976). 1993;18(6):737-747.

2. Cole T, Veeravagu A, Zhang M, Li A, Ratliff JK. Intraoperative neuromonitoring in single-level spinal procedures: a retrospective propensity score-matched analysis in a national longitudinal database. Spine (Phila Pa 1976). 2014;39(23):1950-1959.

5. Eggspuehler A, Sutter MA, Grob D, Jeszenszky D, Porchet F, Dvorak J. Multimodal intraoperative monitoring (MIOM) during cervical spine surgical procedures in 246 patients. Eur Spine J. 2007;16(Suppl 2):S209-S215.

8. Meyer PR Jr, Cotler HB, Gireesan GT. Operative neurological complications resulting from thoracic and lumbar spine internal fixation. Clin Orthop Relat Res. 1988;(237):125-131.

3. May DM, Jones SJ, Crockard HA. Somatosensory evoked potential monitoring in cervical surgery: identification of pre- and intraoperative risk factors associated with neurological deterioration. J Neurosurg. 1996;85(4):566-573.

6. Sutter MA, Eggspuehler A, Grob D, Porchet F, Jeszenszky D, Dvorak J. Multimodal intraoperative monitoring (MIOM) during 409 lumbosacral surgical procedures in 409 patients. Eur Spine J. 2007;16(Suppl 2):S221-S228.

Spring 2021

Vertebral Columns

9. Smith PN, Balzer JR, Khan MH, et al. Intraoperative somatosensory evoked potential monitoring during anterior cervical discectomy and fusion in nonmyelopathic patients—a review of 1,039 cases. Spine J. 2007;7(1):83-87.

isass.org

CLINICAL PRACTICE

From the Hospital for Special Surgery in New York, New York

Prone Lateral Surgery Why Do It? Is It Worth It? The lateral approach to the lumbar spine for interbody fusion has become an increasingly popular choice among spine surgeons since its introduction in the early 1990s. Lateral interbody fusion techniques offer several advantages to surgeons, including reduced blood loss, shorter hospital stay, and—perhaps most importantly—the ability to place large interbody grafts to minimize the risk of subsidence and increase fusion rates.1–3 While these benefits have led to widespread adoption of lateral interbody techniques, there are important limitations to this technique. Frequently cited limitations of the lateral approach include the risk of neurologic complications and the need to reposition the patient to perform posteriorly based procedures to achieve fusion, alignment correction, decompression, etc.1,4,5 Furthermore, in patients who require multilevel fusions to the pelvis (eg, degenerative scoliosis or deformity) (Figure 1), the lateral position does not always allow access to the L5-S1 level; in effect, this requires either multiple position changes (anterior, lateral, then posterior) or a posterior fusion despite operating laterally. The same limitations apply in patients whose neurovascular anatomy at L4-L5 is not conducive to the lateral approach. Faced with this clinical scenario, some surgeons may elect to skip the lateral approach to avoid prolonging operating time

isass.org

and approach-related morbidity. However, two techniques have been developed to overcome these limitations: single position surgery and the prone lateral approach. Single position Sravisht Iyer, MD surgery has been discussed in this newsletter before.6 Briefly, it involves performing anterior lumbar interbody fusion (ALIF), lateral lumbar interbody fusion (LLIF), and percutaneous screw placement all in the lateral position.7 Although single position James Dowdell, MD surgery recoups the time lost to re-positioning, there is a steep learning curve associated with placing pedicle screws in the lateral position.7 Additionally, there are concerns that lordosis correction may be more limited in the lateral position than in the Karim Shafi, MD prone position. The prone lateral approach has been developed as an alternative “single position” technique. Instead of the “traditional” lateral positioning, LLIF is performed with the patient in the prone position. This allows for more straightforward posterior instrumentation, avoids excessive operating room use, and can accommodate more advanced posterior techniques, such as osteotomies, to allow for more aggressive alignment correction.

Vertebral Columns

Spring 2021

CLINICAL PRACTICE

Figure 1. Preoperative (A) anteroposterior and (B) lateral radiographs of a patient indicated for prone lateral surgery.

Figure 2. (A) Axial and (B) sagittal magnetic resonance images show posterior laminectomies and severe foraminal stenosis. The patient did have an anterior psoas at L4-L5 (green circle), which made the lateral approach more challenging.

Spring 2021

Vertebral Columns

Furthermore, the prone position may afford increased lordosis by virtue of hip extension. For example, Miyazaki et al8 demonstrated a significant increase in L4-L5 segmental lordosis compared to lateral decubitus positioning. This finding was evident both intraoperatively and at 2-year follow-up.8 Although prone positioning decreases technical challenges associated with posterior techniques, there is a commensurate increase in the technical difficulty of the lateral approach. Prone positioning is associated with more soft tissue accumulation between the skin and the lumbar spine. As a result, longer retractors, larger incisions, and more careful dissection is required to directly visualize the psoas and avoid inadvertent peritoneal injury. 9 Early experience suggests that the lateral approach increases operative duration and requires increased radiation in the prone position. Gravity may act to pull the retractors and instruments more anteriorly; thus, surgeons must pay careful attention to the position of their instruments and trials relative to the anterior aspect of the disc space. Finally, the prone lateral approach does not obviate the neurovascular risks associated with any lateral technique; a thorough analysis and evaluation of each patient’s unique muscular anatomy remains critical to employing this approach (Figure 2). However, anecdotal evidence suggests that hip extension on the Jackson frame causes posterior translation of the psoas muscle and higher electromyography thresholds compared to lateral approaches. 9 Early reports on the prone lateral technique seem to suggest that it is a safe alternative to

isass.org

CLINICAL PRACTICE

the more traditional lateral approach. It is important to note that these early case reports have notable conflicts of interest and were performed by surgeons who performed several thousand traditional lateral approaches.9-11 The currently available data certainly indicate some role for prone lateral approaches moving forward. In comparing prone lateral and traditional lateral approaches, Godzik et al9 noted that the prone lateral approach had advantages in lordosis generation, screw placement, and posterior facetectomy/decompression (Figure 3), whereas the traditional lateral approach was preferable for obese patients. Similarly, in patients with more challenging anatomy (eg, high iliac crest), a more traditional lateral approach would be preferred. As with any new technique, a careful evaluation of indications and thorough reporting of complications is critical before widespread adoption. n

Figure 3. Post-operative (A) anteroposterior and (B) lateral radiographs after prone lateral fusion from L2-L5.

References 1. Salzmann SN, Shue J, Hughes AP. Lateral lumbar interbody fusion—outcomes and complications. Curr Rev Musculoskelet Med. 2017;10:539-546. 2. Berjano P, Lamartina C. Far lateral approaches (XLIF) in adult scoliosis. Eur Spine J. 2013;22(suppl 2):S242-S253. 3. Fujibayashi S, Hynes RA, Otsuki B, Kimura H, Takemoto M, Matsuda S. Effect of indirect neural decompression through oblique lateral interbody fusion for degenerative lumbar disease. Spine. 2015;40(3):E175-E182. 4. Pereira EAC, Farwana M, Lam KS. Extreme lateral interbody fusion relieves symptoms of spinal stenosis and low-grade spondylolisthesis by indirect decompression in complex patients. J Clin Neurosci. 2017;35:56-61.

isass.org

5. Elowitz EH, Yanni DS, Chwajol M, Starke RM, Perin NI. Evaluation of indirect decompression of the lumbar spinal canal following minimally invasive lateral transpsoas interbody fusion: radiographic and outcome analysis. Minim Invasive Neurosurg. 2011;54(5-6):201-206.

8. Miyazaki M, Ishihara T, Abe T, et al. Effect of intraoperative position in single-level transforaminal lumbar interbody fusion at the L4/5 level on segmental and overall lumbar lordosis in patients with lumbar degenerative disease. Medicine (Baltimore). 2019;98(39):e17316.

6. Iyer S, Barber L. Robot-assisted single-position surgery. Vertebral Columns. Fall 2020:14-17

9. Godzik J, Ohiorhenuan IE, Xu DS, et al. Single-position prone lateral approach: cadaveric feasibility study and early clinical experience. Neurosurg Focus. 2020;49(3):E15.

7. Blizzard DJ, Thomas JA. MIS single-position lateral and oblique lateral lumbar interbody fusion and bilateral pedicle screw fixation: feasibility and perioperative results. Spine (Phila Pa 1976). 2018;43(6):440-446.

10. Lamartina C, Berjano P. Prone single-position extreme lateral interbody fusion (Pro-XLIF): preliminary results. Eur Spine J. 2020;29(suppl 1):6-13. 11. Pimenta L, Amaral R, Taylor W, et al. The prone transpsoas technique: preliminary radiographic results of a multicenter experience. Eur Spine J. 2021;30(1):108-113.

Vertebral Columns

Spring 2021

TECHNOLOGY

From The Core Institute in Mesa, Arizona.

SPECT/CT and Pain Generators in the Spine Hype or Evidence Based? Identifying the cause of axial low back pain is a major diagnostic dilemma plag uing t he t reatment of patients with degenerative pathology in the lumbar spine. Degenerative discs, facet arthrosis, spinal instability, and Robert Ravinsky MD, MPH neurological compression may all be sources of back pain. Magnetic resonance imaging (MRI) is a highly sensitive diagnostic modality that provides excellent resolution of soft tissue and neurological structures; however, morphological changes seen on Brandon P. Hirsch, MD MRIs of aging spines are often asymptomatic.1 Successful outcomes after lumbar spine surgery are highly dependent on accurate identification of the patient’s pain generators. Attempts to avoid incomplete treatment of a patient’s back pain often involve a multilevel fusion procedure. This “shotgun approach” can lead to unfavorable outcomes as complication risk increases with an increased magnitude of surgery. The shortcomings of MRI in identifying specific pain generators have led researchers to seek additional modalities that can aid in diagnosis. Single photon emission computed tomography (SPECT/CT) has emerged as a

Spring 2021

Vertebral Columns

potentially useful diagnostic modality in this patient population. SPECT/CT is a nuclear medicine study in which radiotracer is used to identify areas of increased metabolic activity within bone (Figure 1). This modality is an extension of conventional uniplanar bone scans but is acquired three-dimensionally and merged with a CT image for higher image resolution (Figure 2).2 The earliest studies of SPECT/CT use in the diagnosis of low back pain focused on detection of facetogenic pain. 3,4 In a 2007 study, McDonald et al3 reported on 37 patients who underwent SPECT/CT, identifying 117 facet joints with increased tracer uptake. Targeted facet joint injections were then carried out with 36 of the 37 patients experiencing pain reduction for an average of 2.2 months. The visual analog score for back pain improved by an average of 4.4 points, from 7.2 ± 1.3 before injection to 2.8 ± 1.6 after injection.3 The authors concluded that SPECT/CT was highly predictive of response to interventional treatment of lumbar facetogenic pain.3 In a randomized controlled trial of 80 patients, Jain et al4 evaluated whether patients undergoing interventional treatments targeted at facetogenic or sacroiliac joint pain were more likely to find relief when pre-procedure SPECT/CT was used to target pain generators. They found that the proportion of patients

isass.org

TECHNOLOGY

achieving greater than 50% pain relief after targeted anesthetic block was significantly higher in patients who received pre-procedure SPECT/CT than in those who had not (32 of 40 vs. 21 of 40; P<0.05).4 SPECT/CT also appears to aid in predicting the response of axial neck and back pain after spinal fusion procedures. Ravindra et al5 utilized SPECT/CT in a series of 7 patients to assist in the diagnosis of upper cervical facet arthropathy. These 7 patients all had focal unilateral uptake within the facet joints at either C1-2 or C2-3 and went on to have a selective single level posterior fusion surgery. Despite varying responses to image-guided injection into these joints, all but one patient had significant reduction in their neck pain following surgery.5 Brusko et al6 reported that in a series of 23 patients receiving cervical or lumbar fusion for axial symptoms targeted on the basis of SPECT/CT, 82% of patients had significant improvement in their pain at 1-year follow-up. The findings of these studies were corroborated by a large study of SPECT/ CT in surgically treated patients. Tender et al7 studied 189 patients with positive SPECT/CT. Of these, 86 patients had images that were focally positive at 2 or fewer areas and were offered surgery. Of those offered surgery, 48 patients underwent 1- or 2-level cervical or lumbar fusion procedures for axial pain complaints. The authors reported a significant reduction in axial pain scores from 9.0 ± 1.4 to 4.3 ± 2.3 (P=0.03).7 No control group was included, making it difficult to determine whether patients who undergo such procedures on the basis of medical history, physicial examination, and the

isass.org

Figure 1. Left: T2-weighted sagittal MRI of the lumbar spine without remarkable findings that would indicate the site of pain-causing pathology. Right: Bone SPECT/CT image of the lumbar spine showing a hotspot in the vertebral discs of L3/4 and L4/5. Source: Kato et al. Utility of bone SPECT/CT to identify the primary cause of pain in elderly patients with degenerative lumbar spine disease. J Orthop Surg Res. 2019;14:185.

Figure 2. Left: SPECT/CT volume-rendered image. Right: SPECT/CT coronal image. Source: Scheyerer et al. SPECT/CT for imaging of the spine and pelvis in clinical routine: a physician’s perspective of the adoption of SPECT/CT in a clinical setting with a focus on trauma surgery. Eur J Nucl Med Mol Imaging. 2014;41(S1):59-66.

appearance of MRI would have fared better or worse than those having surgery directed by a preoperative SPECT/CT. SPECT/CT may also be useful in diagnosing pseudarthrosis and instrumentation loosening after spinal fusion, although the data are less robust in this area.8 Rager et

Vertebral Columns

Spring 2021

TECHNOLOGY

al9 described results of SPECT/CT in six patients who underwent repeat operations for pseudarthrosis. In all six patients, SPECT/ CT uptake was increased around the site of loosened pedicle screws. 9 However, of the five surgically confirmed pseudarthroses at the site of interbody fusion, SPECT/CT was positive in only two. 9 In a similarly small series of 8 patients with surgically confirmed pseudarthroses, SPECT/CT was positive in 7 cases.10 The largest study of SPECT/CT included 54 patients with suspected pseudarthrosis after lumbar fusion, finding a sensitivity and specificity of 81% and 83% for posterolateral pseudarthrosis with 100% sensitivity and 60% specificity for detection of interbody pseudarthrosis.11 Although it does seem that SPECT/ CT can add useful diagnostic information in cases where there is uncertainty about fusion status, this modality should not be used in

isolation to determine the need for reoperation. Rather, SPECT/CT can be viewed as one additional piece of diagnostic information to be considered alongside the patient’s history of symptoms and other imaging studies. The limited data available on the ability of SPECT/CT to identify pain generators within the spine suggests that it may offer an advantage over traditional modalities. Spine surgeons should consider using SPECT/CT when faced with diagnostic uncertainty in patients with primarily axial symptoms and/ or a history of prior spine surgery. In doing so, surgeons should understand that SPECT/CT is not 100% sensitive or specific and should view results in the context of all available clinical information. Additional research is needed to demonstrate the utility of this imaging technique in improving clinical outcomes as compared to conventional imaging alone. n

References 1. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(3):403-408. 2. Russo VM, Dhawan RT, Dharmarajah N, Baudracco I, Lazzarino AI, Casey AT. Hybrid bone single photon emission computed tomography imaging in evaluation of chronic low back pain: correlation with Modic changes and degenerative disc disease. World Neurosurg. 2017;104:816-823. 3. McDonald M, Cooper R, Wang MY. Use of computed tomography-single-photon emission computed tomography fusion for diagnosing painful facet arthropathy. Technical note. Neurosurg Focus. 2007;22(1):E2. 4. Jain A, Jain S, Agarwal A, et al. Evaluation of efficacy of bone scan with SPECT/CT in the management of low back pain: a study supported by differ-

Spring 2021

Vertebral Columns

ential diagnostic local anesthetic blocks. Clin J Pain. 2015;31(12):1054-1059. 5. Ravindra VM, Mazur MD, Bisson EF, Barton C, Shah LM, Dailey AT. The usefulness of single-photon emission computed tomography in defining painful upper cervical facet arthropathy. World Neurosurgery. 2016;96:390-395. 6. Brusko GD, Perez-Roman RJ, Tapamo H, Shelby Burks S, Serafini AN, Wang MY. Preoperative SPECT imaging as a tool for surgical planning in patients with axial neck and back pain. Neurosurg Focus. 2019;47(6):E19. 7. Tender GC, Davidson C, Shields J, et al. Primary pain generator identification by CTSPECT in patients with degenerative spinal disease. Neurosurg Focus. 2019;47(6):E18. 8. Al-Riyami K, Gnanasegaran G, van den Wyngaert T, Bomanji J. Bone SPECT/

CT in the postoperative spine: a focus on spinal fusion. Eur J Nucl Med Mol Imaging. 2017;44(12):2094-2104. 9. Rager O, Schaller K, Payer M, Tchernin D, Ratib O, Tessitore E. SPECT/CT in differentiation of pseudarthrosis from other causes of back pain in lumbar spinal fusion: report on 10 consecutive cases. Clin Nucl Med. 2012;37(4):339-343. 10. Damgaard M, Nimb L, Madsen JL. The role of bone SPECT/CT in the evaluation of lumbar spinal fusion with metallic fixation devices. Clin Nucl Med. 2010;35(4):234-236. 11. Heimburger C, Hubele F, Charles YP, et al. Bone scan SPECT/CT for the diagnosis of late complications after spinal fusion: definition and evaluation of interpretation criteria. Medecine Nucleaire. 2015;39:105-121.

isass.org

From the Department of Orthopaedic Surgery at the Hospital for Special Surgery in New York, New York (Drs. Bovonratwet and Qureshi) and Weill Cornell Medical College in New York, New York (Dr. Qureshi).

PATIENT OUTCOMES

Comparison of Perioperative Outcomes Between Awake and Conventional Minimally Invasive Transforaminal Lumbar Interbody Fusion There have been major improvements in surgical procedures, anesthetic techniques, and rehabilitation protocols for spinal fusion that have greatly improved perioperative outcomes. In particular, advancements in regional anesthesia have recently allowed for awake spinal fusion.1 Awake spinal fusion employs multimodal anesthesia with techniques in minimally invasive surgery (MIS) and has some preliminary data showing improved outcomes in patients undergoing MIS transforaminal lumbar interbody fusion (TLIF).1,2 However, even without general endotracheal intubation in awake spine surgery, there remains a continuum of sedation and patient responsiveness. In other words, the patient is not truly “awake.” As with any new surgical pathway, patient selection is crucial. Currently, awake MIS TLIF is typically recommended for 1- or 2-level surgeries with a surgical cut-off time of no more than 120 minutes.1 Some authors have described using a combination of infiltrated liposomal bupivacaine and spinal anesthesia to allow surgical time to extend

isass.org

beyond 120 minutes. 3 Surgical time is a critical component for awake spine surgery because surgeries longer than the estimated time may require intraoperative conversion to general anesthesia, which requires repositioning the patient supine.2 In addition, using sedation in the prone position for extended periods of time may lead to respiratory compromise.2

Patawut Bovonratwet, MD

Perioperative Outcomes Neurological Monitoring Compared with conventional Sheeraz A. Qureshi, general anesthetic techniques, MD, MBA awake MIS TLIF has the unique advantage of allowing the patient to provide live feedback, if needed, during the operation. 2 This is particularly important when there is any significant pressure or tension on neural structures. However, in awake surgical cases in which spinal anesthesia is utilized concurrently, this advantage may be less pronounced.

Vertebral Columns

Spring 2021

PATIENT OUTCOMES

Although awake MIS TLIF has been shown to reduce length of stay, direct data on cost comparison between awake versus conventional spinal fusion is scarce. Operative Time and Postoperative Complications Comparative data between awake versus conventional MIS TLIF in large prospective trials or even large retrospective studies is currently lacking. However, one study by Sekerak et al4 did demonstrate statistically significant reductions in total operative time, which the authors defined as total time in the operating room, for patients undergoing awake MIS TLIF. Their study included 29 MIS TLIF patients who received spinal anesthesia (awake group) and 46 MIS TLIF patients who received general anesthesia. Patients in the awake group had a total operative time of 164 minutes compared to 196 minutes in the general anest hesia group (P<0.05). 4 There were no other statistical differences in rates of nausea/vomiting or 30-day readmissions between the two groups in their study.4 Postoperative Pain and Opioid Consumption In terms of other postoperative outcomes, Sekerak et al4 also showed statistically significant reductions in immediate postoperative pain as well as opioid consumption. Patients who received spinal anesthesia

Spring 2021

Vertebral Columns

reported less maximum postoperative pain (awake group, 3.31 ± 1.41 out of 10, vs general anesthesia group, 5.96 ± 0.84 out of 10; P<0.05) and required less opioid analgesics (awake group, 2.38 ± 1.37 doses, vs general anesthesia group, 5.39 ± 0.84 doses; P<0.05) in the postoperative care unit. The rate of patients requiring opioids in the postoperative care unit was also less for patients in the awake group than in the general anesthesia group (62% vs 87%, respectively; P<0.05).4

Postoperative Length of Stay In a case series of 10 patients, Wang et al1 reported a mean length of stay of 1.4 nights for patients who underwent awake MIS TLIF. This reflected a reduction of more than 2 hospital days on average when compared to their prior reported cohort that utilized conventional anesthesia.1 The authors attributed this reduction in length of stay to the reduced side effects of general anesthesia as well as the utilization of liposomal bupivacaine, which provided prolonged local analgesia up to 3 days postoperatively.1,5 Sekerak et al4 also reported that patients who received spinal anesthesia (awake group) had reduced length of stay compared to those who received general anesthesia (0.97 vs 1.30 days, respectively), though this finding was not statistically significant (P=0.091). Patient-Reported Outcomes Patient-reported outcome measures (PROMs) have become an important tool for measuring patient postoperative improvement.6 Currently, no direct comparative data on PROMs exist between awake versus conventional

isass.org

PATIENT OUTCOMES

MIS TLIF. In one large case series, Kolcun et al7 studied 100 consecutive awake MIS TLIF patients and reported a mean reduction in the Oswestry Disability Index (ODI) of -12.3 (P<0.05) at 1-year follow-up. Although the authors did not include a direct comparison group, a different previous study demonstrated the minimal clinically important difference for ODI to be a reduction of 7.7 at 1-year follow-up after conventional TLIF.8

Cost Effectiveness There has been increasing interesting in reducing costs of care for spine surgery due to the high financial burden associated with these procedures.9 Although awake MIS TLIF has been shown to reduce length of stay,1 direct data on cost comparison between awake versus conventional spinal fusion is scarce. In the study by Sekerak et al,4 the awake group had a net operative cost that was $812.31 lower than that of the general

anesthesia group. However, this finding was not statistically significant (P=0.225) and warrants larger studies focusing on cost effectiveness.

Conclusions Awa ke MIS TLIF has show n promising initial results for improving postoperative pain control, decreasing hospital length of stay, and decreasing costs of care. However, appropriate patient selection cannot be understated. Certain patient populations, such as those with high body mass index, chronic obstructive pulmonary disease, or obstructive sleep apnea, may not be appropriate candidates due to risk of respiratory compromise in the prone position w ith sedation. Future large prospective studies are warranted to rigorously quantify the benef its of awake spinal fusion as well as def ine appropriate patient selection criteria. n

References 1. Wang MY, Grossman J. Endoscopic minimally invasive transforaminal interbody fusion without general anesthesia: initial clinical experience with 1-year follow-up. Neurosurg Focus. 2016;40(2):E13. 2. Garg B, Ahuja K, Sharan AD. Awake spinal fusion. J Clin Orthop Trauma. 2020;11(5):749-752. 3. Kai-Hong Chan A, Choy W, Miller CA, Robinson LC, Mummaneni PV. A novel technique for awake, minimally invasive transforaminal lumbar interbody fusion: technical note. Neurosurg Focus. 2019;46(4):E16. 4. Sekerak R, Mostafa E, Morris MT, et al. Comparative outcome analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery. J Clin Orthop Trauma. 2021;13:122-126.

isass.org

5. Butler AJ, Brusko GD, Wang MY. Awake endoscopic transforaminal lumbar interbody fusion: a technical note. HSS J. 2020;16(2):200-204. 6. Guzman JZ, Cutler HS, Connolly J, et al. Patient-reported outcome instruments in spine surgery. Spine (Phila Pa 1976). 2016;41(5):429-437. 7. Kolcun JPG, Brusko GD, Basil GW, Epstein R, Wang MY. Endoscopic transforaminal lumbar interbody fusion without general anesthesia: operative and clinical outcomes in 100 consecutive patients with a minimum 1-year follow-up. Neurosurg Focus. 2019;46(4):E14.

8. Adogwa O, Elsamadicy AA, Han JL, Cheng J, Karikari I, Bagley CA. Do measures of surgical effectiveness at 1 year after lumbar spine surgery accurately predict 2-year outcomes? J Neurosurg Spine. 2016;25(6):689-696. 9. Kahn EN, Ellimoottil C, Dupree JM, Park P, Ryan AM. Variation in payments for spine surgery episodes of care: implications for episode-based bundled payment. J Neurosurg Spine. 2018;29(2):214-219.

Vertebral Columns

Spring 2021

PAYMENT MODELS

From the DISC Sports and Spine Center in Marina del Rey and Newport Beach, California.

Why All Physicians Should Go Out of Network—And Why They Probably Won’t For many key healthcare players across t he United States, t he prevailing effort to bring down medical costs involves paying physicians less. These efforts are orchestrated by large organizations (eg, America’s Health Grant D. Shifflett, MD Insurance Plans, Centers for Medicare and Medicaid Ser v ices) w it h tremendous amounts of money and power. Power is wielded through control of large numbers of patient lives and aggressive lobbies at the state and federal level in an effort to manipulate legislation. These institutions are far from beholden to the Hippocratic Oath, as patient outcomes and satisfaction take a back seat to the bottom line. These attributes make for a David vs Goliath matchup with physicians who are poorly organized, fiercely independent, politically complacent (or inactive), and frankly more interested in patient well-being than their own financial success. The calculated, organized effort to drive down physician reimbursement has been successful because of the ability to push providers toward “in-network” participation with health plans. For a variety of reasons, physicians have unfortunately played right into this strategy. Due to the administra-

Spring 2021

Vertebral Columns

tive challenges of running independent and small practices, many physicians and physician groups have consolidated and/or been bought out by health systems. Many providers—particularly the younger generation of doctors—have opted to work as employees for large health systems, which make all their decisions for them. This has resulted in fewer physicians capable of achieving and maintaining an out-ofnetwork status irrespective of how high quality their care may be. The demonization of “out-of-network” medicine has been a key component of pushing providers toward in-network participation and has largely been accomplished t h roug h ag g ressive leg islat ive ef for ts. Legislative initiatives across the country at both the state and federal levels1-4 have allowed insurance companies to weaponize surprise medical billing to achieve their long-term goal of making it harder for out-of-network providers to get paid and shifting more providers in network. 5 Although there is no denying that there have been issues with inappropriate medical billing, many of these issues pertain to unique types of out-of-network situations (eg, emergency rooms, hospitals, inpatient care). Nevertheless, these legislative efforts

isass.org

PAYMENT MODELS

widely impact many providers who practice out of network in other surgical and outpatient settings. Many of these physicians provide high-quality out-of-network care using transparent and ethical processes. However, these types of providers incur a much higher cost to insurers and are major targets for cost reduction. By using the very attractive and newsworthy story about the “out of network pathologist that the patient never met,” insurance companies may be able to generate enough outcry to end all out-of-network care. Physicians are in a very difficult position to negotiate based on these conditions. How can physicians find an opportunity to flip the script? The answer lies in the fact that no matter what happens, physicians will always have the power of the prescription pad—medical care ceases to exist without physicians making diagnoses and prescribing treatment. As discussed in a previous issue, physicians could consider unionizing to form this power into a unified collective bargaining front, but this option is untenable for a number of reasons. 6 A similar but equally powerful option would be the informal election by all providers across all specialties to simply go out of network. Insura nce compa nies ca n on ly dr ive payments down because they can pit one provider against another. If no provider accepted any insurance, then insurers would be forced to revisit the usual and customary payments they make. Determination of payments would also likely have to be re-evaluated. W ho would get paid more and why? Quality metrics and outcomes

isass.org

could play a role. Certainly, market forces would be at work instead of the current completely arbitrary race to the bottom in terms of which providers are willing to take the lowest payment. This idea sounds great, but the question remains: “Would it work?” Probably not. And even if it might, would physicians even do it? The answer there is likely a resounding “No, they would not.” For starters, I have come to understand that many physicians are notoriously independent, are poor businesspeople, and struggle with working together toward a common goal—an issue further complicated by the incredibly diverse range of specialties and interests unique to each group of providers. Furthermore, most of the physicians I have encountered have spent most of their lives “keeping their heads down” and “pushing through” challenging situations. Many adopt the same approach to their clinical practice, so garnering their attention to rally behind this cause would be challenging at best. In my experience, many physicians chose medicine because of the certainty and job security it affords; the fear of going out of network and losing patients and/or losing their jobs would be unpalatable. Collectively going out of network would only work if everyone got on board, and admittedly, there are probably enough providers who would cross the line and make a deal with insurers to take the business for any price. The threshold necessary to meet “in-network” credentialing status is incredibly low and could easily be satisfied. Also, many providers are employees of a

Vertebral Columns

Spring 2021

PAYMENT MODELS

Collectively going out of network would only work if everyone got on board, and admittedly, there are probably enough providers who would cross the line and make a deal with insurers to take the business for any price.

hospital or a large conglomerate. Shifting to out-of-network practice would require these individuals to void their contracts, a nd t hei r employers wou ld more t ha n li kely just f i l l t heir posit ions w it h t he aforementioned providers who “crossed the line.” Most devastating to this plan is the reality that patients would feel the hurt financially until insurers renegotiated their rates or changed their out-of-network benefits. Insurers would blame this issue on physicians, ask patients to pick up the

tab for payments, and many would have very poor access to care, particularly low income families that could not afford the care. These likely consequences would not sit well with physicians. Despite being the most critical player, physicians continue to lose ground in the overall control of patient care, from medical decisions about what diagnostics or treatment they require, to how and where they receive their care, to how they are compensated for their provision of care. Insurers operate under a model of maximal pressure—patients are squeezed by soaring premiums and high deductibles while access to care diminishes and physicians are forced to go through arduous bureaucratic and administrative processes to simply provide care and are getting paid progressively less. At some point, enough is enough and a seismic shift is necessary. Physicians need to unite and go out of network—and maybe we should all drop Medicare while we’re at it. n

References 1. Health care coverage: out-of-network coverage, AB 72 (Cal 2016). https:// leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201520160AB72. Accessed April 9, 2021. 2. Patient Protection and Affordable Care Act, HR 3590, 111th Cong (2010). https:// www.congress.gov/bill/111th-congress/ house-bill/3590. Accessed April 9, 2021. 3. Lower Health Care Costs Act, S 1895, 116th Cong (2020). https://www. congress.gov/bill/116th-congress/senate-bill/1895. Accessed April 9, 2021.

Spring 2021

Vertebral Columns

4. Consolidated Appropriations Act, HR 133, 116th Cong (2020). https://www. congress.gov/bill/116th-congress/ house-bill/133. Accessed April 9, 2021.

6. Shifflett G. A power struggle: exploring physician unions as a method for regaining control from payers. Vertebral Columns. Winter 2021:22-25.

5. Adler L, Duffy E, Ly B, Trish E. California saw reduction in out-of-network care from affected specialties after 2017 surprise billing law. USC-Brookings Schaeffer on Health Policy. September 26, 2019. https://www.brookings.edu/blog/ usc-brookings-schaeffer-on-health-policy/2019/09/26/california-saw-reductionin-out-of-network-care-from-affectedspecialties-after-2017-surprise-billing-law. Accessed April 9, 2021.

isass.org