Two Surgeon Approach for Complex Spine Surgery

Rationale, Outcome, Expectations, and the Case for Payment Reform

Jennifer M. Bauer, MD, MS; Vijay Yanamadala, MD, MBA; Suken A. Shah, MD; Rajiv K. Sethi, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(9):e408-e413. 

In This Article

Abstract and Introduction

Abstract

There is an increased trend in complex spine deformity cases toward a two attending surgeon approach, but the practice has not become widely accepted by payers. Multiple studies have shown that spine surgery complications increase with the duration of case, estimated blood loss, and use of transfusions, as well as in certain high-risk populations or those requiring three-column osteotomies. Dual-surgeon cases have been shown to decrease estimated blood loss, transfusion rate, surgical times, and therefore complication rates. Although this practice comes at an uncertain price to medical training and short-term costs, the patient's quality of care should be prioritized by institutions and payers to include dual-surgeon coverage for these high-risk cases. Because we enter an era where the value of spine care and demonstrating cost-effectiveness is essential, dual surgeon attending approaches can enhance these tenets.

Introduction

Surgeries with two attending surgeons have recently grown in popularity, but there are many factors at play when considering the dual-surgeon approach for spine deformity surgery. A recent survey of the Scoliosis Research Society (SRS) found that most members suggest that a second surgeon in adult spine deformity (ASD) cases improves safety and outcomes and decreases complications (Figure 1).[1] However, these surgeons sometimes limit their use of a second surgeon because of difficulty with reimbursement (Figure 2). Currently, two attending surgeons of the same specialty can work together, but the second surgeon can only bill as an assistant, which carries a significantly decreased work relative unit value. Although surgeons of two different specialties can work together as cosurgeons for a modest increase in the total work relative unit value, this work needs to be addressed further. Neurosurgeons and orthopaedic surgeons increasingly collaborate in the treatment of ASD, but pediatric deformity remains primarily an orthopaedic subspecialty. Therefore, pediatric orthopaedic surgeons have little economic advantage from the reimbursement perspective to standardize dual-surgeon practice for their most challenging spine cases. Intraoperative data, such as blood loss, surgical time, and complication rates, have shown improvement with two-surgeon complex deformity cases and should be examined in the context of clinical outcomes, health care costs, and surgeon training for both adult and pediatric spine deformity.

Figure 1.

Bar diagram showing percent of "yes" and "no" responses to the 2015 SRS survey on single versus dual attending surgeon for ASD. ASD = adult spine deformity, SRS = Scoliosis Research Society (Reproduced with permission from Scheer JK, Sethi RK, Hey LA, et al: Results of the 2015 Scoliosis Research Society Survey on single versus dual attending surgeon approach for adult spinal deformity surgery. Spine 2017;42:932–942.)

Figure 2.

Circle graph showing reasons to limit the use of a second surgeon in ASD, from the 2015 SRS survey on single versus dual attending surgeon. ASD = adult spine deformity, SRS = Scoliosis Research Society (Reproduced with permission from Scheer JK, Sethi RK, Hey LA, et al: Results of the 2015 Scoliosis Research Society Survey on single versus dual attending surgeon approach for adult spinal deformity surgery. Spine 2017;42:932–942.)

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