A reproducible and reliable localization technique for lumbar spine surgery that minimizes unintended-level exposure and wrong-level surgery

Patel, Akshar V.; Runner, Robert P.; Bellamy, J; Rhee, John M.

doi:10.1016/j.spinee.2018.12.005

Cited by 6 publications

(12 citation statements)

References 15 publications

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“…Universal Protocol-JCAHO (Joint Commission on Accreditation of Healthcare Organizations), Time Outs, and the 3R's) are aimed at avoiding WLS, WSS, and WSSS [Table 1]. [1,[2][3][4][5][6][7][8][9][10]12,14,[16][17][18][19][20] Clarke et al (2008) used the 3 step R protocol (i.e. right patient, right side, and right level), Time Outs, and marking the correct site to avoid WSSS.…”

Section: Use Of the Universal Protocol Time Outs And The 3 R's To Avoid Wrong Level Surgery (Wls) Wrong Side Surgery (Wss) And Wrong Sitementioning

confidence: 99%

“…right patient, right procedure, right location/side) should largely limit/eliminate the first two "errors, " WLS and WSS still occur with an unacceptable frequency. [1,2,[4][5][6][7]10,12,14,[16][17][18][19][20] Here, we reviewed the incidence of WLS and WSS in 20 studies, and looked at the major factors contributing to these "errors;" spinal anomalies/anatomic variants, and failure to obtain adequate intraoperative X-rays/Fluoroscopic images (i.e. inadequate number, inadequate quality, poor/misinterpretation of X-rays/fluoroscopic images).…”

Section: Introductionmentioning

confidence: 99%

“…failure to "speak up"), fatigue, rushing/ emergent procedures, and others). [1,2,[4][5][6][7]10,12,14,[16][17][18][19][20] Our aim in highlighting the main failures contributing to WLS/WSS/WSSS should help limit/eliminate them in the future.…”

Section: Introductionmentioning

confidence: 99%

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

Epstein¹

2021

Surgical Neurology International

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Background: Four of the most common “errors” in spine surgery include: operating on the wrong patient, doing the wrong procedure, performing wrong-level surgery (WLS), and/or performing wrong-sided surgery (WSS). Although preoperative verification protocols (i.e. Universal Protocol, routine Time-Outs, and using the 3 R’s (i.e. right patient, right procedure, right level/side)) have largely limited the first two “errors,” WLS and WSS still occur with an unacceptably high frequency. Methods: In 20 studies, we identified the predominant factors contributing to WLS/WSS; unusual/anatomical anomalies/variants (i.e. sacralized lumbar vertebrae. lumbarized sacral vertebra, Klippel-Feil vertebrae, block vertebrae, butterfly vertebrae, obesity/morbid obesity), inadequate/poor interpretation of X-rays/fluoroscopic intraoperative images, and failure to follow different verification protocols. Results: “Human error” was another major risk factor contributing to the failure to operate at the correct level/side (WLS/WSS). Factors comprising “human error” included; surgeon/staff fatigue, rushing, emergency circumstances, lack of communication, hierarchical behavior in the operating room, and failure to “speak up”. Conclusion: Utilizing the Universal Protocol, routine Time Outs, and the 3 R’s largelly avoid operating on the wrong spine patient, and performing the wrong procedure. However, these guidelines have not yet sufficiently reduced the frequently of WLS and WSS. Greater recognition of the potential pitfalls contributing to WLS/WSS as reviewed in this perspective should better equip spine surgeons to avert/limit such “errors” in the future.

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Section: Use Of the Universal Protocol Time Outs And The 3 R's To Avoid Wrong Level Surgery (Wls) Wrong Side Surgery (Wss) And Wrong Sitementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Epstein¹

2021

Surgical Neurology International

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“…Several reports have been published with recommendations to aid in the identification of the appropriate spinal level during the pre- and intraoperative period. 10,15 -17 These localizing techniques involve utilizing a metallic marker on an anatomical landmark during the exposure of the spine, and reliably interpreting some form of imaging intraoperatively. Ultimately, prevention relies on proper education beginning at the resident and fellow level of training regarding the pitfalls in avoiding WSSS, and it appears that formal education regarding this potentially avoidable complication is limited.…”

Section: Preventionmentioning

confidence: 99%

An Update on Wrong-Site Spine Surgery

DeVine

Chutkan

Gloystein

et al. 2020

Global Spine Journal

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Study Design: Broad narrative review of current literature and adverse event databases. Objective: The aim of this review is to report the current state of wrong-site spine surgery (WSSS), whether the Universal Protocol has affected the rate, and the current trends regarding WSSS. Methods: An updated review of the current literature on WSSS, the Joint Commission sentinel event statistics database, and other state adverse event statistics database were performed. Results: WSSS is an adverse event that remains a potentially devastating problem, and although the incidence is difficult to determine, the rate is low. However, given the potential consequences for the patient as well as the surgeon, WSSS remains an event that continues to be reported alarmingly as often as before the implementation of the Universal Protocol. Conclusions: A systems-based approach like the Universal Protocol should be effective in preventing wrong-patient, wrong-procedure, and wrong-sided surgeries if the established protocol is implemented and followed consistently within a given institution. However, wrong-level surgery can still occur after successful completion of the Universal Protocol. The surgeon is the sole provider who can establish the correct vertebral level during the operation, and therefore, it is imperative that the surgeon design and implement a patient-specific protocol to ensure that the appropriate level is identified during the operation.

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“…31 With newer techniques and technologies, various localization modalities have been developed that utilize fluoroscopy or plain radiography in conjunction with fiducial marking of an anatomical landmark. [32][33][34] Still, the continued prevalence of wrong-level surgery underscores its limitations. While intraoperative imaging has mostly become common practice, its use is not universal among providers.…”

Section: Wrong-level Surgerymentioning

confidence: 99%

Medical malpractice in spine surgery: a review

Medress¹,

Jin²,

Feng³

et al. 2020

Neurosurgical Focus

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Medical malpractice is an important but often underappreciated topic within neurosurgery, particularly for surgeons in the early phases of practice. The practice of spinal neurosurgery involves substantial risk for litigation, as both the natural history of the conditions being treated and the operations being performed almost always carry the risk of permanent damage to the spinal cord or nerve roots, a cardiopulmonary event, death, or other dire outcomes. In this review, the authors discuss important topics related to medical malpractice in spine surgery, including tort reform, trends and frequency of litigation claims in spine surgery, wrong-level and wrong-site surgery, catastrophic outcomes including spinal cord injury and death, and ethical considerations.

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A reproducible and reliable localization technique for lumbar spine surgery that minimizes unintended-level exposure and wrong-level surgery

Cited by 6 publications

References 15 publications

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

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

An Update on Wrong-Site Spine Surgery

Medical malpractice in spine surgery: a review

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