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Editorial
2019
:10;
132
doi:
10.25259/SNI-344-2019
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Based upon 7.2% of the Eligible Voting Members, the American Association of Neurological Surgeons (AANS) Suspended Dr. Nancy E. Epstein for Arguing Against Unnecessarily Extensive Spine Surgery

Professor of Clinical Neurosurgery, School of Medicine, State University of New York at Stony Brook and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital, NYU Winthrop NeuroScience/Neurosurgery, Mineola, New York 11501, USA.
Corresponding author: Nancy E. Epstein, M.D., NYU Winthrop Hospital, NYU Winthrop NeuroScience/ Neurosurgery, 200 Old Country Rd. Suite 485, Mineola, NY 11501, USA. nancy.epsteinmd@gmail.com
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How to cite this article: Epstein NE. The AANS suspends Editor in Chief, Nancy Epstein, for telling the truth about spine surgery. Surg Neurol Int 2019;10:132.
Articles Documenting Risks of TLIF Chrastil et al. Spine 2013: 17 articles about the complications with BMP TLIF/PLIF; these included heterotopic ossification within the epidural space or neuroforamina, postoperative radiculitis, and endplate osteolysis with interbody device subsidence. Zhang et al. Medicine 2016 confirms the comparable efficacy of fusion for PLF vs. TLIF. Bakhsheshian et al. J Clin Neurosci 2016 further confirmed 5 MIS TLIF graft/cage extrusions in 513 patients Joseph et al. Neurosurg Focus 2015: 5454 MI TLIF: 1045 complications-rate per patient was 19.2% in the MI-TLIF group … sensory, temporary neurological deficits, permanent neurological deficits respectively 20.16%, 2.22%, and 1.01% for MI-TLIF … Rates of intraoperative and wound complications were 3.57% and 1.63% for MI- TLIF Giorgi et al. Orthop Traumatol Surg Res 2015: MI TLIF 182 cases: The rate of postoperative complications was 7.7%. Liu J, Eur Spine J 2016: In this series, 101 TLIF: 2 cases (1.9 %) root dysfunction, dural tears TLIF 4 cases (3.9 %)., re-operation rate TLIF 2 cases (1.9 %), wound infection TLIF 5.0% Klingler et al. Scientific World Journal 2015: more durotomy with MIS TLIF: 372 patients: 32 durotomies (514 levels) (6.2%). Correlated with age over 65 and obesity (Marlowe 66 and obese) Norton Spine 2015: Degenerative spondylolisthesis: Patients who had TLIF + higher risk of mortality than patients who had PLF Nixon AT Surgical Neurol Int. 2014 Of 340 TLIF, 4 (1.2%) new lower extremity weakness (with degenerative spondylolisthesis). Park Y Clin Orthop Surg 2015: Perioperative complications occurred in 9% of TLIF patients (11/124); including three postoperative neuralgia, two deep wound infections, two pedicle screw misplacements, two cage migrations, one dural tear, and one grafted bone extrusion Hoy K, Eur Spin J 2013: TLIf vs. PLF (instrumented): 51 patients had TLIF, 47 PLF.). No statistic difference in outcome between groups could be … Operation time and blood loss in the TLIF group were significantly higher than in the PLF group. Wang J, Zhou Y, Spine J. 2014 Sep 1;14(9):2078-84. They noted the reported incidence of perioperative complications associated with MIS-TLIF surgery is highly variable. They found 75 perioperative complications in 204 patients (36.76%); 31.37% (64/204 patients) in the MIS-TLIF operations; seven (9.33%) were classified as persistent and 68 (90.67%) were classified as transient. Wong AP et al. J Neurosurg Spine. 2015 May;22(5):487-95. They analyzed intraoperative and perioperative complications in 513 consecutive MI-TLIF-treated patients with lumbar degenerative disc disease….The perioperative complication rate was 15.6%; durotomy was 5.1%, and the medical and surgical infection rates were 1.4% and 0.2%.
My candor on the stand may well have been the reason Drs. McLaughlin and Joseffer were not found liable at trial.
As recently as February 14, 2019, counsel for AANS misstated the issue and the role of the disciplinary process, stating: “[T] he underlying issue to be decided by the general membership with respect to Dr. Epstein’s testimony is whether TLIF’s fall within generally accepted neurosurgical practice, along with other approaches, or whether the procedure constitutes a violation of the standard of care for lumbar stenosis with spondylolisthesis.” Ex. 9 (last par.). But this was an issue in the malpractice case. It is not the issue in this disciplinary proceeding. The only question is whether I violated the Expert Rules. Ex. 4.
https://zneurosurgery.com/wp-content/uploads/2014/05/AANS-Rules-for-Neurosurgical-Medical-Legal-Expert- Opinion-Services-2006.pdf
Dr. Epstein’s argument that her research found higher reported rates of surgical complications in TLIF surgery than for posterolateral fusion surgery similarly does not change that fact that TLIF is widely practiced and within the standard of care.

This is the fourth and final editorial describing my experience with the AANS and the AANS Expert Witness Rules. As explained in my first editorial (“Why I testify for some patients/ plaintiffs, and against some doctors/defendants”), I testify in cases in which I believe the plaintiff/ patient was a victim of unnecessary, inappropriate, and/or negligent surgery. In my second editorial (“Does the American Association of Neurological Surgeons seek to limit members from testifying for patients/plaintiffs through proceedings resembling a kangaroo court and/or star chamber?”), I supplied evidence for my opinion that the answer to that question is YES! Finally, in the third editorial (“The American Association of Neurological Surgeons (AANS) Suspends Surgeon for Arguing Against Unnecessarily Extensive Spine Surgery; Was this Appropriate?”), I detailed the AANS’ actions up to and including the Nov. 16, 2018 AANS’ Board of Directors’ decision that I be suspended for 6 months. Here is what happened next.

According to the AANS rules, after the Board of Directors recommends a suspension, I can appeal their decision to the membership, which I did. Until recently the members voted on the appeal at the general business meeting. Interestingly, these rules were changed in 2018. According to the new procedures, members are now asked to vote electronically without the benefit of any discussion at the business meeting. In any case, consistent with the new AANS procedures, I wrote a letter stating my case (attachment A) and the President of the AANS wrote a letter to the members (attachment B) in response. Upon viewing the Presidents letter, I sent an email to the President (attachment C) detailing several misleading statements, and in some cases frank misrepresentations of the truth. Both attachments A and B were available on the internet for the voting members of the AANS to see prior to their voting electronically, but attachment C was not.

There are several troubling aspects of what ensued. First, my corrections, attachment C, regarding the inaccuracy in the President’s letter, were never conveyed to the membership. Second, I documented that two members of the AANS Board had clear conflicts of interest (COI). In one case, in April 2018, I had previously alerted the AANS of Dr. Haid’s COI, yet he was at the Nov 16th Board meeting, although he allegedly abstained from the vote (see appendix A). In the second case, I only learned after the Nov. 16th meeting that another member of the Board, Dr. Schaffrey, the President-elect of the AANS at that time, had a clear COI, having received substantial money from the manufacturer of the instrumentation involved in the TLIF, according to ProPublica. Yet, he took an active part in the proceedings of Nov 16th, including questioning me, although he did “abstain” for the vote. The AANS lawyer, informed us via letter that “The AANS requires members serving on committees to submit conflict of interest disclosure forms in connection with their service.” However, either this was not true in this case or the AANS allows individuals to take part in discussions when they have a clear COI. As the current President, Dr. Schaffrey signed the letter suspending me based upon “a majority vote of those voting members of the AANS casting ballots”. Finally, we learned from the AANS lawyer that only 500 of the 5400 AANS members eligible to vote actually voted; 389 voted in favor of the Board’s recommendation, 104 voted against it (in my favor), and 7 ballots were without a vote. Thus, I was suspended based upon the vote of 7.2% of the AANS members!

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The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Journal or its management.

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