Wrong site surgery of the spine
Presentation
On April 28, 2016, a 42-year-old man came to Neurosurgeon A on referral for neck pain with radiation to his upper arms and numbness. The patient’s history included a surgery on his right hand and medications included cyclobenzaprine and meloxicam.
Neurosurgeon A reviewed an MRI scan that revealed severe compression at C5-C6 and C6-7 with effacement of his spinal cord and severe foraminal impingement. The surgeon recommended a C5-6 and C6-7 anterior discectomy and fusion.
Physician action
On May 25, 2016, Neurosurgeon A took the patient to surgery. In the operative note, the surgeon mentioned that x-rays confirmed the location at C5-6 and C6-7. Hospital records show that two fluoroscopic images, interpreted by Radiologist A, were submitted from the OR showing surgical hardware was present from C5-C7. However, another hospital record indicated that the fluoroscopic images were submitted but there was not a radiology interpretation. The surgery was completed without complications, and the patient reported that he was doing well at his first postoperative visit approximately four weeks later.
On August 11, the patient returned for a six-week-follow-up and reported pain in his lumbar spine and symptoms of radiculopathy. A lumbar MRI was ordered and showed degenerative disc disease at L5-S1 without broad-based protrusion that touched the right and left S1 nerve root without canal stenosis or significant neuroforaminal narrowing.
At an October 3 visit, Neurosurgeon A diagnosed the patient with L5 sciatica. During this visit, the physician discussed the option of a hemilaminectomy and foraminotomy. The patient agreed to the surgery and scheduled it for November 23. However, the patient cancelled the surgery on November 22.
The patient began treatment with a pain management physician who performed epidural steroid injections on June 25, 2017, and December 19, 2017. The physician documented the patient’s history as including a C6-T1fusion in May 2016. The patient reported that since
the 2016 surgery he experienced numbness, tingling, headaches, and right-sided neck pain with radiation and a right C6 distribution. A cervical MRI taken in November 2018 showed a disc bulge at C5-6 resulting in mild right foraminal narrowing.
Neurosurgeon B performed a C5-C6 fusion and removed the previously placed hardware from C6-T1. The surgery lessened the patient’s symptoms of pain, numbness, and tingling.
Allegations
The patient filed a lawsuit against Neurosurgeon A alleging a wrong-level surgery of the spine. Instead of performing surgery at C5-6 and C6-7, the neurosurgeon performed the anterior discectomy and fusions at C6-7 and C7-T1.
Legal implications
The consultant physicians who reviewed this case agreed that Neurosurgeon A performed surgery at the unintended C6-7 and C7-T1 levels, instead of the C5-6 and C6-7 levels. One orthopedic surgeon stated that the safest and most common method for identifying the correct level in this type of surgery is via intraoperative x-ray or fluoroscopy that allows the surgeon to make a “marking shot.” None of the intraoperative imaging performed during the May 2016 surgery reflects that a marking shot was established, nor does Neurosurgeon A describe doing so in his operative report.
Another consultant criticized Neurosurgeon A for not obtaining post-fusion diagnostic imaging to confirm that the hardware was at the correct levels.
Disposition
This case was settled on behalf of Neurosurgeon A.
Risk management considerations
In a 2008 survey of members of the American Academy of Neurological Surgeons, 50 percent of responding surgeons reported that they had performed “one or more” wrong-level surgeries during their career. Not only can a surgeon potentially operate on the wrong side of the spine or the wrong level, but specific challenges exist related to spinal localization. In the survey, examples of wrong-site surgeries included surgical intervention at the incorrect location, performing the wrong procedure, or operating on the wrong patient. (1)
However, wrong-site surgery can occur in all surgical specialties. Thankfully, effective strategies from organizations such as the Joint Commission and the National Association of Spine Specialists (NASS) have proven to help minimize the risk of wrong-site surgery. In these guidelines, both organizations stress the importance of strong communication between the surgical team and the patient as an essential preventative measure. This includes all participants in a surgery — surgical team and, when possible, the patient — be involved in marking the site of surgery. Involving the patient helps to ensure that everyone understands the surgery to be performed and allows the surgical team to confirm that the intended surgery matches the patient's symptoms and diagnosis.
Source
1. Mody MG, Nourbakhsh A, Stahl DL, et. al. The prevalence of wrong level surgery among spine surgeons. Spine. Volume 33, Issue 2. January 15, 2008.