Wrong-level spine surgery is a devastating error that can result in unnecessary risks, patient harm, legal consequences, and loss of trust in the healthcare system. Given the complexity of spinal anatomy, precise localization of the surgical level is critical. This article explores proactive strategies to prevent wrong-level spine surgery and outlines measures to mitigate the consequences if such an error occurs.
Understanding Wrong-Level Spine Surgery
Wrong-level spine surgery occurs when a surgeon mistakenly operates at an adjacent or incorrect spinal level rather than the intended target. This can happen due to:
- Misinterpretation of imaging
- Anatomical variations
- Poor intraoperative localization
- Failure to follow standard verification protocols
This mistake can lead to inadequate symptom relief, additional surgeries, patient distress, and potential litigation.
Causes of Wrong-Level Spine Surgery: The Role of Anatomical Variations
Common Anatomical Variations Leading to Wrong-Level Surgery
1. Transitional Vertebrae
One of the most common causes of wrong-level surgery is the presence of lumbosacral transitional vertebrae (LSTV). These include lumbarisation of S1 or sacralisation of L5, leading to ambiguity in vertebral counting. This variation can cause confusion, especially if preoperative imaging is not meticulously correlated with intraoperative findings.
2. Vertebral Numbering Variations
The normal human spine consists of 7 cervical, 12 thoracic, and 5 lumbar vertebrae. However, congenital variations can result in additional or absent vertebrae, making level identification difficult. A patient with an extra lumbar vertebra (L6) may have an incorrect level labeled if the surgical team relies solely on standard anatomical expectations.
3. Congenital Fusions and Anomalies
Congenital anomalies, such as Klippel-Feil syndrome (cervical vertebral fusion) or congenital hemivertebrae, alter the usual landmarks used for intraoperative localization. In such cases, standard reference points like C7-T1 junction or the iliac crest may not provide reliable guidance.
4. Variability in Rib and Iliac Crest Landmarks
Surgeons often use the iliac crest to approximate L4-L5 and the lowest rib to identify the thoracolumbar junction. However, these landmarks can vary between individuals, particularly in taller or shorter patients, leading to miscounting.
5. Spinal Deformities
Scoliosis, kyphosis, or rotational abnormalities can distort normal spinal alignment, causing vertebral bodies to appear displaced in imaging. If the numbering is inconsistent across imaging modalities, there is a heightened risk of targeting the wrong level.
6. Postoperative Changes from Prior Surgery
Patients with prior spinal instrumentation or laminectomies may present with altered bony landmarks due to surgical resection, bone regrowth, or hardware placement. In such cases, previously relied-upon anatomic references may no longer be accurate.
Strategies to Prevent Wrong-Level Spine Surgery
1. Preoperative Planning and Verification
- Detailed Imaging Studies: Ensure that high-quality MRI and CT scans are performed and correlated with clinical symptoms.
- Surgeon’s Personal Review: The operating surgeon should personally review all imaging and correlate findings with patient complaints and physical examination.
- Multidisciplinary Case Discussions: When needed, cases should be discussed in multidisciplinary meetings to confirm the diagnosis and surgical plan.
2. Standardised Marking and Verification Protocols
- Preoperative Consent and Marking:
- The surgeon should mark the surgical site with the patient awake and confirm the level with the patient.
- Informed consent should explicitly mention the targeted spinal level.
- Checklists and Protocols:
- Implementing WHO surgical safety checklists that include spinal level verification.
- Double-checking the surgical plan with nurses, anaesthesiologists, and assistants.
Its a good practice to mention the mobile segment from below to help the surgeon know the correct level in addition to the actual level mentioned. For eg: lumbar 4/lumbar 5 discectomy (second mobile segment from below)
3. Intra-operative Imaging and Localisation
- Fluoroscopy/X-ray Verification:
- Use of Radiopaque Markers:
- Placing radiopaque markers on the patient’s skin or instrumentation at the anticipated level helps in real-time confirmation.
- Using pre-placed fiducial markers or percutaneous needles at adjacent landmarks assists with localization.
- Intra-operative CT or O-arm Navigation- can be used for localisation Intra-operatively, if in doubt.Intra- operative CT scan alone may be used without navigation if navigation is unavailable.
- Ultrasound Assistance:
- Intraoperative ultrasound can be used as an adjunct imaging modality to confirm spinal landmarks in certain cases.
4. Additional Measures to Prevent Errors
- Dual Surgeon Verification:
- Having a second surgeon or senior colleague verify the level before proceeding can add an extra layer of safety.
- Electronic Medical Record (EMR) Cross-Check:
- Cross-referencing the planned surgical level with detailed EMR documentation ensures consistency.
- Patient Engagement:
- Reconfirming symptoms and anatomical location with the patient preoperatively to ensure alignment with imaging findings.
5. Surgeon and Team Communication
- Time-Out Protocol:
- Conduct a surgical time-out where the entire team verifies the correct patient, procedure, and surgical level before proceeding.
- Clear Role Assignments:
- Each member of the team should have a role in verification, ensuring multiple layers of checks.
6. Training and Quality Assurance
- Regular Training:
- Surgeons should participate in continuous medical education focused on error prevention strategies.
- Data Analysis and Audits:
- Hospitals should analyse past errors, conduct morbidity and mortality reviews, and implement improvements based on findings.
Mitigation Measures if Wrong-Level Surgery Occurs
Despite best efforts, wrong-level surgery can still occur. The response must be prompt, transparent, and patient-centred.
1. Immediate Recognition and Correction
- Intraoperative Identification:
- If identified intraoperatively, immediate correction should be undertaken if the patient’s condition allows.
- Minimal Additional Tissue Damage:
- If proceeding with the correct surgery in the same session, efforts should be made to minimize further trauma.
2. Postoperative Disclosure and Management
- Full Disclosure to Patient and Family:
- Honest, compassionate communication with the patient about what happened, why, and the corrective measures taken.
- Institutional and Legal Reporting:
- The incident should be reported internally and, if required, to medical boards or health authorities.
- Root Cause Analysis:
- Conduct a thorough review to understand what led to the error and implement corrective strategies.
3. Patient Support and Long-Term Care
- Medical and Psychological Support:
- Offer additional medical care, rehabilitation, and psychological support to affected patients.
- Compensation and Legal Considerations:
- If needed, institutions should have protocols in place for fair compensation and avoiding lengthy litigation.
Let me conclude….
Wrong-level spine surgery is a serious but preventable event. By implementing rigorous preoperative planning, intraoperative verification, and a culture of safety, healthcare teams can significantly reduce the risk. If an error does occur, prompt identification, transparent communication, and corrective action are essential to mitigating consequences and maintaining trust in patient care. Continuous learning and technological advancements will further aid in minimising these surgical errors in the future.