A perspective on wrong level, wrong side, and wrong site spine surgery

Epstein, Nancy E.

doi:10.25259/sni_402_2021

Cited by 13 publications

(6 citation statements)

References 23 publications

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“…Off-by-one vertebral body misalignments are relatively prevalent due to approximate translational symmetry of the vertebral column. Similar errors have been demonstrated in other treatment modalities, for example human mistakes combined with low quality images have been known to cause spinal surgery errors [18,19].…”

Section: Introductionsupporting

confidence: 58%

Automated detection of vertebral body misalignments in orthogonal kV and MV guided radiotherapy: application to a comprehensive retrospective dataset

Charters,

Luximon,

Petragallo

et al. 2024

Biomed. Phys. Eng. Express

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Objective: In image-guided radiotherapy (IGRT), off-by-one vertebral body misalignments are rare but potentially catastrophic. In this study, an automated method to detect such misalignments with IGRT radiographs was investigated using densely-connected convolutional networks (DenseNets) for applications towards real-time error prevention and retrospective error auditing. Approach: A total of 4213 images acquired from 527 radiotherapy patients aligned with planar kV or MV radiographs were used to develop and test error-detection software modules. Digitally reconstructed radiographs (DRRs) and setup images were retrieved and co-registered according to the clinically applied alignment contained in the DICOM REG files. A semi-automated algorithm was developed to simulate patient positioning errors on the anterior-posterior (AP) and lateral (LAT) images shifted by one vertebral body. A DenseNet architecture was designed to classify either AP images individually or AP and LAT image pairs. Receiver-operator characteristic curves (ROC) and areas under the curves (AUC) were computed to evaluate the classifiers on test subsets. Subsequently, the algorithm was applied to the entire dataset in order to retrospectively determine the absolute off-by-one vertebral body error rate for planar radiograph guided RT at our institution from 2011-2021. Main results: The AUCs for the kV models were 0.98 for unpaired AP and 0.99 for paired AP-LAT. The AUC for the MV AP model was 0.92. For a specificity of 95%, the paired kV model achieved a sensitivity of 99%. Application of the model to the entire dataset yielded a per-fraction off-by-one vertebral body error rate of 0.044% [0.0022%, 0.21%] for paired kV IGRT including one previously unreported error. Significance: Our error detection algorithm was successful in classifying vertebral body positioning errors with sufficient accuracy for retrospective quality control and real-time error prevention. The reported positioning error rate for planar radiograph IGRT is unique in being determined independently of an error reporting system.

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Section: Introductionsupporting

confidence: 58%

Automated detection of vertebral body misalignments in orthogonal kV and MV guided radiotherapy: application to a comprehensive retrospective dataset

Charters,

Luximon,

Petragallo

et al. 2024

Biomed. Phys. Eng. Express

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“…There is substantial literature supporting protocolized timeouts and intraoperative radiographs in spine surgery due to the difficulty in utilizing external landmarks. [21][22][23] However, reflexive, dual radiograph interpretation with formal radiology consultation in the intraoperative setting does not appear to provide substantial value in a large series of patients undergoing spine surgery for a wide variety of indications. This study is not without limitations.…”

Section: Discussionmentioning

confidence: 99%

Formal Radiologist Interpretations of Intraoperative Spine Radiographs Have Low Clinical Value

Lin,

Dalton,

Como

et al. 2024

Spine

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Study Design. Retrospective cohort. Objective. To evaluate the clinical relevance, usefulness, and financial implications of intraoperative radiograph interpretation by radiologists in spine surgery. Summary of Background Data. Due to rising healthcare costs, spine surgery is under scrutiny to maximize value-based care. Formal radiographic analysis remains a potential source of unnecessary healthcare costs, especially for intra-operative radiographs. Methods. A retrospective cohort analysis was performed on all adult elective spine surgeries at a single institution between July 2020 and July 2021. Demographic and radiographic data was collected, including intraoperative localization and post-instrumentation radiographs. Financial data was obtained through the institution’s price estimator. Radiographic characteristics included time from radiographic imaging to completion of radiologist interpretation report, completion of radiologist interpretation report prior to the conclusion of surgical procedure, clinical relevance, and clinical usefulness. Reports were considered clinically relevant if spinal level of the procedure was described and clinically useful if completed prior to conclusion of the procedure and deemed clinically relevant. Results. 481 intraoperative localization and post-instrumentation radiographs from 360 patients revealed a median delay of 128 minutes between imaging and completion of interpretive report. Only 38.9% of reports were completed before conclusion of surgery. There were 79.4% deemed clinically relevant and only 33.5% were clinically useful. Localization reports were completed more frequently before conclusion of surgery (67.2% vs. 34.4%), but with lower clinical relevance (90.1% vs. 98.5%) and clinical usefulness (60.3% vs. 33.6%) than post-instrumentation reports. Each patient was charged $32-$34 for interpretation fee, cumulating a minimum total cost of $15,392. Conclusion. Formal radiographic interpretation of intraoperative spine radiographs was of low clinical utility for spine surgeons. Institutions should consider optimizing radiology workflows to improve timeliness and clinical relevance or evaluate the necessity of reflexive consultation to radiology for intraoperative imaging interpretation to ensure that value-based care is maximized during spine surgeries. Level of Evidence. 3

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“…The literature suggests it is not an uncommon one. Higher estimations suggest that over half of spine surgeons will encounter at least one wrong-level spine surgery (WLSS) in their career [44][45][46] .…”

Section: Specific Problems In Spinal Surgery: Wrong Level Spine Surgerymentioning

confidence: 99%

The Relevance of World Health Organization Surgical Safety Checklist to Spinal Surgery

Munigangaiah,

Davies-Jones

2024

MRAJ

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Across the 193 member states of the World Health Organization (WHO) an estimated 234 million operations were conducted worldwide in 2008 (1 per every 25 human beings on the planet). These numbers have continued to increase to 312.9 million by 2016. Surgical errors involving the wrong site, wrong procedure or wrong patient occur at a rate of 1 in 112,000. This equates to 2,000 estimated ‘never events’ every year with a significant associated physical and psychological burden on patients and surgeons and financial and reputational burden on health organisations involved in litigation for such errors. The WHO Surgical Safety Checklist (WHOSSC), produced in 2009 is now synonymous with safety in the operating theatre. This checklist imposes a process of scrutiny at the key steps of the patients journey through theatre. The key details scrutinised have been shown to improve patient outcomes and theatre efficiency. Several studies have looked at adapted checklists specific to different specialties and it is becoming clearer that whilst the overall benefit of the original checklist is undeniable, in some speciality areas a more deliberate and nuanced application of the checklist to address specific problems could be of value. As a specialism, spinal surgery differs from others with a significant risk of a perioperative complication leading to harm and morbidity, permanent disability or even death. Iatrogenic spinal cord injury requires high-level resources and prolonged, sometimes lifelong rehabilitation. Other complications include cerebrospinal fluid leak, blood loss, new neurologic deficit, hardware failure, proximal junctional failure, pseudarthrosis, and surgical site infection. Wrong level spinal surgery (WLSS) is a complication specific to spinal surgery and studies have reported WLSS effecting 50-68% of spinal surgeons at some point in their career. The risks of these complications can be mitigated by factors, some of which are included in the WHOSSC and others with are lacking. This scoping review looks at how surgical checklists; both the original and modified versions have and could be used to address the surgical safety challenges specific to spinal surgery.

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A perspective on wrong level, wrong side, and wrong site spine surgery

Cited by 13 publications

References 23 publications

Automated detection of vertebral body misalignments in orthogonal kV and MV guided radiotherapy: application to a comprehensive retrospective dataset

Automated detection of vertebral body misalignments in orthogonal kV and MV guided radiotherapy: application to a comprehensive retrospective dataset

Formal Radiologist Interpretations of Intraoperative Spine Radiographs Have Low Clinical Value

The Relevance of World Health Organization Surgical Safety Checklist to Spinal Surgery

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