Spinal Exposure Surgeons

[1ightningz]

Is this a lucrative/popular field to go into? Supposedly an area of need where I'm from (several docs moved/retired). I've often heard them referred to as "vascular surgeons" but it seems like they're just general surgeons without fellowship who just go around doing exposure for ALIFs for the numerous spine docs in town.

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[Smurfette]

Is this a lucrative/popular field to go into? Supposedly an area of need where I'm from (several docs moved/retired). I've often heard them referred to as "vascular surgeons" but it seems like they're just general surgeons without fellowship who just go around doing exposure for ALIFs for the numerous spine docs in town.

It reimburses well, but usually the surgeons who do these do them as part of their larger practice. In other words, they normally don't do only these procedures, and it's not considered it's own specialty, but more of a niche. Because they expose the large vessels (aorta and iliacs, which are retracted away from the spine during the procedure), they are also the ones who manage any bleeding, which is often torrential "audible bleeding" when it happens, and tend to be viewed as vascular surgeons by the spine folks despite possibly not being true vascular-trained surgeons. Most of the time the cases go well, but when they go bad, they can go very, very bad and be quite stressful.

 

[Doc mu]

It reimburses well, but usually the surgeons who do these do them as part of their larger practice. In other words, they normally don't do only these procedures, and it's not considered it's own specialty, but more of a niche. Because they expose the large vessels (aorta and iliacs, which are retracted away from the spine during the procedure), they are also the ones who manage any bleeding, which is often torrential "audible bleeding" when it happens, and tend to be viewed as vascular surgeons by the spine folks despite possibly not being true vascular-trained surgeons. Most of the time the cases go well, but when they go bad, they can go very, very bad and be quite stressful.

Wait...So spine surgeons need literally a whole vascular surgeon to do their exposures? what if a vascular surgeon is not present or they are in a spine only/ortho only group PP? it also just seems very inefficient, the spine surgeons here do all their own exposures from what i've seen

 

[1ightningz]

Wait...So spine surgeons need literally a whole vascular surgeon to do their exposures? what if a vascular surgeon is not present or they are in a spine only/ortho only group PP? it also just seems very inefficient, the spine surgeons here do all their own exposures from what i've seen

From what i've seen it's only for L5-S1 anterior exposure

 

[Pir8DeacDoc]

Wait...So spine surgeons need literally a whole vascular surgeon to do their exposures? what if a vascular surgeon is not present or they are in a spine only/ortho only group PP? it also just seems very inefficient, the spine surgeons here do all their own exposures from what i've seen

I occasionally do the exposure for the spine guys on ACDF. They like another set of hands on revision cases, multi level (especially lower in the neck), and the older folks with swallowing issues. There's no hard and fast rule. But I help out a handful of times a year. I suspect the same might be true for access surgeons in the lower spine (i.e. general/vascular surgeons). But maybe others can weight in

 

[akwho]

Spine folks do most of their own exposures but for select ALIF cases they do have a general/vascular surgeon do the exposure through the retroperitoneum since they are more familiar operating through it.

The ALIF's have some structural correction benefits and increased rates of spinal fusion so it's an advantageous procedure for certain patients vs going all posterior which is a spinal surgeons bread and butter.

I've never heard of a spine doc needing help for ACDF exposure, that's interesting. It's usually the spine fellow doing the exposure in an academic practice.

 

[Pir8DeacDoc]

Spine folks do most of their own exposures but for select ALIF cases they do have a general/vascular surgeon do the exposure through the retroperitoneum since they are more familiar operating through it.

The ALIF's have some structural correction benefits and increased rates of spinal fusion so it's an advantageous procedure for certain patients vs going all posterior which is a spinal surgeons bread and butter.

I've never heard of a spine doc needing help for ACDF exposure, that's interesting. It's usually the spine fellow doing the exposure in an academic practice.

Certainly not the norm- they can do their own stuff 99% of the time. But something we (ENT) did rarely in residency for the Neurosurgeons (no spine fellows) and I was asked to do at my current hospital. It's usually on the re-do stuff where the tissue planes are shot or they want to spread liability in case they bag the recurrent nerve LOL

 

[Wordead]

Spine folks do most of their own exposures but for select ALIF cases they do have a general/vascular surgeon do the exposure through the retroperitoneum since they are more familiar operating through it.

The ALIF's have some structural correction benefits and increased rates of spinal fusion so it's an advantageous procedure for certain patients vs going all posterior which is a spinal surgeons bread and butter.

I've never heard of a spine doc needing help for ACDF exposure, that's interesting. It's usually the spine fellow doing the exposure in an academic practice.

I do maybe 5 ACDF exposures a year usually in setting of neck abscess or some other obvious ****show when there's concurrent stabilization procedures needed. Intermittently some of the older spine guys for revision cases or RLN palsy they'll ask for help. They tend to not love calling because we share the coding 50-50. So for 15 mins of work or whatever I code for half of all their procedures. Kind of a raw deal for them.

 

[dpmd]

Wait...So spine surgeons need literally a whole vascular surgeon to do their exposures? what if a vascular surgeon is not present or they are in a spine only/ortho only group PP? it also just seems very inefficient, the spine surgeons here do all their own exposures from what i've seen

I doubt they do their own anterior lumbar exposures

 

[dpmd]

Is this a lucrative/popular field to go into? Supposedly an area of need where I'm from (several docs moved/retired). I've often heard them referred to as "vascular surgeons" but it seems like they're just general surgeons without fellowship who just go around doing exposure for ALIFs for the numerous spine docs in town.

Not sure what it pays but I don't think it is super popular as evidenced by the fact that the spine guys here have trouble finding someone to do their exposures and have been trying to talk me into starting to do them. There is apparently training you can get for it that they keep offering to pay me to take. But I have no desire to mess around with big blue, big red, or their big branches.

 

[HemeOncHopeful19]

Wait...So spine surgeons need literally a whole vascular surgeon to do their exposures? what if a vascular surgeon is not present or they are in a spine only/ortho only group PP? it also just seems very inefficient, the spine surgeons here do all their own exposures from what i've seen

Yeah IIRC it was one of these guys that ultimately blew the whistle on Chris Duntsch after doing an exposure for him, it’s pretty interesting hearing him interviewed.

 

[1ightningz]

Yeah IIRC it was one of these guys that ultimately blew the whistle on Chris Duntsch after doing an exposure for him, it’s pretty interesting hearing him interviewed.

That guy had to go into rehab himself for either alcohol or drugs and all his partners left his practice.

 

[dienekes88]

Not sure what it pays but I don't think it is super popular as evidenced by the fact that the spine guys here have trouble finding someone to do their exposures and have been trying to talk me into starting to do them. There is apparently training you can get for it that they keep offering to pay me to take. But I have no desire to mess around with big blue, big red, or their big branches.

I did maybe 10 or 15 in residency. I can see how it might be a bit annoying. If you don't do many of them, it can take awhile to do the exposure... especially if the person isn't accustomed to working around the aorta, iliacs, cava, etc. The spine surgeon then does the first level in like 20 minutes and you then have to move the retractors, because the exposure for L4/L5 is distinctly different from the exposure for L5/S1. Then after they finish, you have to close them up. Put it all together, and it can be more than half a day's work if you don't do many of them.

But exactly as above, the familiarity with how to work around the big vessels is why it's usually a vascular surgeon. I would suspect that transplant guys would also be pretty good at this exposure.

 

[dpmd]

I did maybe 10 or 15 in residency. I can see how it might be a bit annoying. If you don't do many of them, it can take awhile to do the exposure... especially if the person isn't accustomed to working around the aorta, iliacs, cava, etc. The spine surgeon then does the first level in like 20 minutes and you then have to move the retractors, because the exposure for L4/L5 is distinctly different from the exposure for L5/S1. Then after they finish, you have to close them up. Put it all together, and it can be more than half a day's work if you don't do many of them.

But exactly as above, the familiarity with how to work around the big vessels is why it's usually a vascular surgeon. I would suspect that transplant guys would also be pretty good at this exposure.

Yeah, I will just stick to putting the vp shunt cath in the belly for them.

 

[longhaul3]

Our thoracic and lumbar access surgeons (very large tertiary center with a lot of disaster spine patients) are general general surgeons. One is predominantly a trauma surgeon; another does ACS-type stuff. None are full-fledged vascular surgeons. Mostly ALIF exposures, but sometimes need thoracic exposure via thoracotomy and dropping a lung. A lot of the complications related to these surgeries are exposure-related like ileus, pneumothorax, etc. While we can manage these complications when they are relatively straightforward, it is nice to have them on board, especially if they placed the chest tube in the first place. I've never seen a spine surgeon do an ALIF exposure unassisted—in fact I'd say it would be easier for the general surgeon to do the ALIF than for the spine surgeon to do the exposure.

We also have a lot of disaster multiple redo cervical spines with prior laryngectomies/airway issues, various kinds of neck cancer s/p radiation, or horrible deformities for whom ENT helps with anterior cervical exposure. Occasionally we will have a patient who also needs a thyroidectomy that they will do at the same time.

 

[Dr.LeoSpaceman]

Not sure what it pays but I don't think it is super popular as evidenced by the fact that the spine guys here have trouble finding someone to do their exposures and have been trying to talk me into starting to do them. There is apparently training you can get for it that they keep offering to pay me to take. But I have no desire to mess around with big blue, big red, or their big branches.

From what I was told by the people that did it when I was in training, it bills pretty well. Someone would have to correct me, but I believe you bill as a co-surgeon (-62) for the actual procedure since the exposure is bundled into the CPT for the spine procedure. So you each end up billing 63% of the RVUs for the case. Considering the RVU haul for spine cases, not a bad deal.

 

[dpmd]

From what I was told by the people that did it when I was in training, it bills pretty well. Someone would have to correct me, but I believe you bill as a co-surgeon (-62) for the actual procedure since the exposure is bundled into the CPT for the spine procedure. So you each end up billing 63% of the RVUs for the case. Considering the RVU haul for spine cases, not a bad deal.

I certainly like my cosurgeon fee for the vp shunt. A nice haul for an hour case and typically no rounding after. I actually got paid so much by one insurance company I was worried they didn't bill the cosurgeon modifier. Sounds like the alif exposures take a lot more time and I would feel obligated to round after due to risk of ileus and such (though the person that currently does exposures doesn't round as evidenced by me getting consulted for a post op ileus). But they deserve whatever they get for being willing to mess around with big vessels.

 

[Dr.LeoSpaceman]

I certainly like my cosurgeon fee for the vp shunt. A nice haul for an hour case and typically no rounding after. I actually got paid so much by one insurance company I was worried they didn't bill the cosurgeon modifier. Sounds like the alif exposures take a lot more time and I would feel obligated to round after due to risk of ileus and such (though the person that currently does exposures doesn't round as evidenced by me getting consulted for a post op ileus). But they deserve whatever they get for being willing to mess around with big vessels.

The ones I remember would only take an hour or so, so still a better return than you'd get on almost anything else. But yeah, definitely would depend on your relationship with the spine surgeon. We wouldn't round on the patients routinely, and would only get called if the patient needed an NG tube. I'm sure there was some agreement among the staff that this was the process, though.

Personally, I'm still junior enough that I hate being the mechanic and not having as much ownership/control over the case, which is why I wouldn't really have interest in doing it even if it was an option.

 

[Lem0nz]

From what I was told by the people that did it when I was in training, it bills pretty well. Someone would have to correct me, but I believe you bill as a co-surgeon (-62) for the actual procedure since the exposure is bundled into the CPT for the spine procedure. So you each end up billing 63% of the RVUs for the case. Considering the RVU haul for spine cases, not a bad deal.

There is a specific CPT code for anterior lumbar spinal exposure. I know because I tried to use it for a spinal sarcoma I exposed for ortho onc and got shot down ~2 months ago that the code was specifically for anterior exposure for fusion. 23.53 RVUs, slightly more than a straightforward colectomy. I would argue more work than a straightforward colectomy but with no anastomosis and minimal follow up needed probably good value in the long run. Definitely see what vascular would be the go to to do it.

You could easily get away with billing as co-surgeon though. No one would blink about it.

 

[dpmd]

There is a specific CPT code for anterior lumbar spinal exposure. I know because I tried to use it for a spinal sarcoma I exposed for ortho onc and got shot down ~2 months ago that the code was specifically for anterior exposure for fusion. 23.53 RVUs, slightly more than a straightforward colectomy. I would argue more work than a straightforward colectomy but with no anastomosis and minimal follow up needed probably good value in the long run. Definitely see what vascular would be the go to to do it.

You could easily get away with billing as co-surgeon though. No one would blink about it.

The spine surgeon has to agree to it though. That cuts into their reimbursement though

 

[Smurfette]

The spine surgeon has to agree to it though. That cuts into their reimbursement though

When my partner did these, he billed a co-surgeon fee (-62 modifier) on the ALIF code, and IIRC as assist (-80 modifier) on the hardware placement. Obviously he'd stay to ensure the vessels were protected and retracted and he would close. Each level counts separately with the hardware, so it adds a bit to the reimbursement to add in all those supplemental codes the spine guy is using as well.

 

[TypeADissection]

I used to do these when I first started out just to get in the OR and build a practice. Billed as co-surgeon and the F/U was super easy in comparison to other patients in my clinic. I stopped doing them as I got busier because it really would just eat into my block and they wouldn't let me schedule anything else while these were going. So I just ended up sitting around all day doing an exposure, placing retractors, going one level higher, then coming back to close; rinse and repeat x 2-3.