The 'Nightmare' of Wrong Level in Spine Surgery: Is Minimally Invasive Spine Technique More Forgiving?

Abstract

Objective: Operating on a wrong level is a nightmare for every surgeon, which has devastating consequences for the patient as well as the surgeon and has potential for serious medical, personal and legal repercussions. There is limited literature of Wrong Level Spine Surgery (WLSS) in Minimally Invasive Spine Surgery (MISS). The aim of the study is to evaluate the incidence of WLSS in MISS using tubular retractors. Methods: The study included a retrospective review of prospectively collected data of all MIS surgeries utilizing tubular retractors during the period extending from January 2007 to December 2014. The surgeries included Micro-Endoscopic Discectomies, Micro-Endoscopic Decompression surgeries for lumbar canal stenosis and Minimal Invasive Trans-Foraminal Lumbar Interbody Fusion (MI-TLIF) surgeries. The surgeries involved docking of the tubular retractor at the level of interest under fluoroscopic guidance. Surgical charts as well as clinical and imaging followup data were analyzed. The incidence of WLSS was analyzed. Results: There were 1,043 surgeries in all in the study period. There were 393 discectomies, 370 decompressions and 280 MI-TLIF surgeries. There were no wrong level surgeries in the entire series. There were two (0.19%) wrong side tube dockings which were subsequently rectified during surgery. No clinical complications were seen. The results were reviewed in light of a meta-analysis of current literature available on WLSS in open and MISS. The results were consistent with the present literature in demonstrating a decreased incidence of WLSS with MISS. Conclusion: The docking of the tubular retractor under fluoroscopic guidance offers an advantage of preventing WLSS. This is an additional benefit of MISS using tubular retractors.

Ultrasonography is more accurate than percutaneous palpation for identifying targeted thoracolumbar intervertebral disc spaces in dogs

“…This rate is in line with the data reported in the human literature . Identifying the wrong intervertebral disc space is considered as a medical, financial, and legal problem in human surgery . From a clinical standpoint, the disease process is not addressed.…”

“…In addition, clients may suffer substantial despair and psychologic distress and may lose trust; the responsible surgeon may experience embarrassment, guilt, and fear . The situation is often perceived as the surgeon's worst night mare because of the impending personal, professional, and legal repercussions . The same issues, at a similar rate, are encountered on veterinary patients and so this problem should be identically considered in veterinary surgery.…”

A Two-year Outcome of Various Techniques of Discectomy On Complications: A Multicentric Retrospective Study

“…This unfortunate event was mostly witnessed in open and micro discectomies which generally need surgical exposure and verification of the level, even after marking and verifying the level before incising the skin. One of the distinct advantages of minimal access surgeries relates to the low to nil risk of performing a wrong level surgery since imaging is required till the endoscope or the tubular retractor is positioned over the segment of interest [24].…”

Full Endoscopic Spine Surgery in the View of Tubular Endoscopic Spine Surgery

“…Ability to carry out decompression as a day care procedure under local anesthesia with conscious sedation is an advantage of both full endoscopy and tubular techniques [17][18][19] . Minimally invasive techniques focus on the site of pathology, so they do involve measures to localise the level before giving skin incision reducing the incidence of wrong level spine surgery than in open technique 44) . Evolution of biportal endoscopic spine and adjacent segment degeneration 22) .surgery expanded the indications identical to those of open technique like disc herniations, stenosis, low-grade spondylolisthesis.…”

“…A paradigm shift from tubular microscopic spine surgery to full endoscopic technique is an attractive potential possibility keeping in mind the smaller portals, magnified view of the operative field and cosmetic scar. Good results have been documented with tubular techniques with limited exposure of visceral surface area to pathogens and reduced incidence of surgical site infections 44) , similar cosmetic advantage and significant patient satisfactory outcomes. The scar left by tubular technique is small and cosmetic too.…”