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A recent review article “Wrong-site Spine Surgery” appearing in the May 2013 Journal of the American Academy of Orthopaedic Surgeons [link] describes the incidence, risk factors and ramifications of spine surgery performed either at the wrong vertebral level or on the wrong patient side. The article recites the findings published in literature authored within both the orthopaedic and neurosurgical medical disciplines. While the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began promoting a surgical protocol designed to prevent wrong-site, wrong-procedure and wrong-person surgery back in 2003, these types of errors were still the most common sentinel events occurring between 2004-2012 . Apparently, the checklist system has done little to prevent wrong site spinal surgery.

According to the article, as many as 50% of spine surgeons report performing at least one wrong-level operation during their careers. A referenced survey of neurosurgeons revealed that 6 of 569 respondents (1.1%) reported performing surgery on the wrong side more than one time. It is suspected that the mistake is likely under-reported, and certainly surveys are only as accurate as the number of doctors who respond to them.

There are a variety of risk factors that are believed to contribute to this type of surgical error:

Potential factors that contribute to WSSS include emergent surgery, patient factors (eg, morbid obesity) anatomic variations secondary to deformity or previous surgery, time pressure to initiate or complete surgery, unusual equipment or setup, multiple surgeons involved in the surgery, multiple procedures being performed during a single surgery, and communication breakdown between the surgical team and the patient and/or the patient’s family.

Many experts advocate the use of an intraoperative marker and x-ray to determine the appropriate level. Unfortunately, “even when a spinal radiograph is obtained, performance of a procedure at an incorrect level may not be obviated because the surgeon may misinterpret the radiograph.”

The consequences to the patient who undergoes a wrong site spine surgery vary. According to the article:

Incorrect side or level decompression will traumatize the paraspinal soft tissues, disrupt the osseoligamentous stabilizing structures, and produce epidural fibrosis. Unplanned tissue disruption may subject the patient to increased postoperative pain, prolonged recovery, and an accelerated degenerative process at the wrong surgical site. In the case of wrong-level arthrodesis, the added level of fusion and/or instrumentation may adversely affect spinal biomechanics and increase the potential for adjacent segment degeneration.

In other words, surgery at the incorrect level not only causes unnecessary injury to the unintended level, but can also subject adjacent levels to additional stress and risk of future harm.

It is common practice in operating rooms nationwide for patients to “sign” a body part with a Sharpie or other permanent marker to identify the right (or wrong) limb prior to going to sleep for surgery. Unfortunately, a patient is not able to play much of a role in marking the vertebral level that needs a discectomy or fusion. According to the article, “the spine surgeon is the only healthcare provider with access to all the information necessary to identify the correct spinal segment at the time of surgery.” The information and tools are available for this preventable medical error to be avoided. That it continues to occur with such frequency is alarming.

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