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Review Article

Wrong-site Spine Surgery

Mark A. Palumbo, MD Aaron J. Bianco, MD Sean Esmende, MD Alan H. Daniels, MD

Wrong-site spine surgery is an adverse event that has potentially devastating consequences for the patient as well as the surgeon. Despite substantial efforts to prevent wrong-site spine surgery, this complication continues to occur and has the potential for serious medical, personal, and legal repercussions. Although systemsbased prevention methods are effective in identifying the proper patient, procedure, and region of the spinal column, they cannot be relied on to establish the correct vertebral level during the operation. The surgeon must design and implement a patientspecic protocol to ensure that the appropriate operation is performed on the correct side and level or levels of the spinal column.

From the Department of Orthopaedic Surgery, the Warren Alpert Medical School of Brown University, Providence, RI. Dr. Palumbo or an immediate family member is a member of a speakers bureau or has made paid presentations on behalf of and serves as a paid consultant to Globus Medical, Stryker, and Medtronic and has received research or institutional support from Globus Medical. Dr. Daniels or an immediate family member has received research or institutional support from Synthes Spine and Flexuspine. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Bianco and Dr. Esmende. J Am Acad Orthop Surg 2013;21: 312-320 JAAOS-21-05-312 Copyright 2013 by the American Academy of Orthopaedic Surgeons.

rong-person, wrong-procedure, and wrong-site surgery were the most common sentinel events reported by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) from 2004 to 2011.1 These events are among the most serious of medical errors, often leading to clinical morbidity, increased healthcare costs, and legal action. Both the patient and physician typically suffer significant emotional harm. Wrong-site spine surgery (WSSS) occurs when a surgeon performs a decompression, resection, or reconstructive procedure on an unintended anatomic location along the spinal axis. WSSS encompasses both wrong-level surgery (ie, an operation performed on an incorrect vertebra or spinal motion segment) and wrong-side surgery.2-7 Surgical exposure of a spinal segment in proximity to the intended surgical level is common and should not be considered a wrong-site operation. Despite ongoing efforts to prevent WSSS, it continues to occur, with up to 50% of spine surgeons reporting

performance of at least one wronglevel operation during the course of their careers.7 The surgeon must remain particularly vigilant against wrong-level spine surgery (WLSS) given the challenge of intraoperative localization of the correct vertebral segment. Precise identification of the correct spinal level requires specialized knowledge and meticulous analysis of radiographic imaging and anatomic landmarks. Patient factors such as body habitus, spinal deformity, and variant vertebral morphology can introduce error or uncertainty with regard to the correct spinal level.8,9 Systems-based prevention is effective for confirming the proper patient and planned procedure and identifying the appropriate region of the spinal column (ie, cervical, thoracic, or lumbar).9,10 These prevention systems, however, cannot be relied on to establish the correct vertebral level during the operation. Accordingly, the use of preoperative checklists is just one component of the overall approach to prevent WSSS.


Journal of the American Academy of Orthopaedic Surgeons

Mark A. Palumbo, MD, et al

Table 1 North American Spine Society Sign, Mark, & X-ray (SMaX) Checklist Involve the patient in conrming the surgical site either through informed consent or during the actual marking. Surgeons are encouraged to personally obtain informed consent. Copies of the surgical permit/informed consent form should state the site and side of surgery and be shared with the patient, surgeon, anesthesiologist, assistant or scrub nurse, and circulating nurse. Sign your name to the surgical site. Each member of the surgical team should verify the correct site. Verify that radiographs and medical records are for the correct patient, as well as conrming the identity of the patient. Each of the following items should be double checked against the marked site: Medical record Radiographs and other imaging studies (marked L or R to prevent being placed backwards on the light box) Informed consent Operating room/anesthesia record Consider having your assistant or scrub nurse always stand opposite the side where the surgeon should stand. Consider or suggest obtaining an intraoperative radiograph after exposure, using markers that do not move to conrm the vertebral level to be operated. Consider a radiology reading. Complete all items listed. Relying on a single preventative effort only can result in errors.
Adapted from North American Spine Society: Sign, Mark & X-ray (SMax): Prevent wrong-site surgery. Available at: Default.aspx.

The spine surgeon is the sole healthcare provider with access to and knowledge of all the information necessary to identify the correct vertebral level or levels and the extent of pathology during surgery. Only the surgeon possesses the training to interpret the preoperative and intraoperative imaging studies, correlate the radiologic findings with surgical anatomy, and execute a procedure that addresses the pathologic lesion. Thus, the surgeon has primarily responsibility for the design and implementation of a patient-specific protocol to ensure that the appropriate procedure is performed at the correct level or levels and side of the spinal column.

Historical Background
The JCAHO5 and the North American Spine Society (NASS)10 have
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published guidelines that promote communication among the surgical team, anesthesia providers, nursing staff, and the patient to reduce the risk of performing an incorrect invasive procedure. In 2003, the JCAHO promoted the Universal Protocol, which was designed to prevent wrong-site, wrong-procedure, and wrong-person surgery.5 This protocol has been endorsed by the American Academy of Orthopaedic Surgeons and NASS. It emphasizes three minimum requirements: preoperative verification, site marking, and a time out in the operating room. Since July 2004, all accredited hospitals and ambulatory care and officebased surgery facilities have been required to implement this protocol. The NASS guidelines are divided into two parts. The Sign, Mark, & X-ray (SMaX) protocol10 is a checklist that can be used to guide the en-

tire surgical team through a series of events intended to decrease the potential for WSSS (Table 1). The second component is the Take-Home Sheet: Patient Diagnosis Diagram. This diagram is provided to the patient and is designed to enhance the patients understanding of the spinal diagnosis and the surgical plan, with instructions provided for identification of the site and side of surgery. NASS recommends that the patient present the sheet to all healthcare providers on the day of surgery to reduce the risk of WSSS. Despite these prevention efforts, wrong-patient, wrong-site, or wrong-procedure events were still the most common sentinel events from 2004 to 2012, accounting for 928 of 6,994 events (13.3%).1 The rate of wrong-site surgical procedures before and after implementation of the Universal Protocol mandate appears unchanged11 and, even under optimal conditions, the protocol may not prevent all cases of wrong-site surgery.12 Little evidence exists to indicate the effectiveness of the Universal Protocol or the NASS guidelines in decreasing the rate of WSSS.3 Although these prevention systems recommend obtaining an intraoperative radiograph to confirm the correct spinal level, the subtleties of spinal segment localization during surgery are not addressed. Therefore, it is unlikely that the goal of eliminating WSSS will be met by adhering solely to the NASS guidelines or the Universal Protocol.

The true incidence of WSSS has been difficult to quantify because of limitations in obtaining an accurate count of events and patients at risk over a specific time period. Devine et al3 reviewed scientific evidence to


Wrong-site Spine Surgery

determine the incidence of WSSS and found that the overall strength of the evidence was poor. Despite the suboptimal quality of evidence, several studies have reported that the incidence of wrong-level lumbar surgery ranges from 0.04 to 5.3%.2,3,7,11,13-15 In the only prospective investigation of WSSS, Ammerman et al16 reported on a case series of lumbar diskectomy procedures and documented a 15% rate of wrong-level exposure but no cases of WSSS. Kwaan et al12 analyzed the incidence of wrong-site surgery based on claims submitted to a malpractice insurer between 1985 and 2004. In total, 1,426,901 inpatient surgical procedures and 1,399,466 outpatient surgical procedures were analyzed. Of the 40 cases of wrong-site surgery identified, 15 (37.5%) involved the wrong level or wrong side of the vertebral column. Among the reviewed spine cases, 7 of 10 were lumbar operations, 5 of which involved anomalous lumbosacral anatomy. In three cases, intraoperative imaging was not used. Jhawar et al14 surveyed neurosurgeons regarding their experience with WSSS in a series of 4,695 lumbar and 2,649 cervical diskectomies. The incidence of wrong-level lumbar surgery was 12.8 per 10,000 procedures, and the incidence of wronglevel cervical surgery per 10,000 cervical diskectomy and craniotomy procedures was 7.6 and 2.0, respectively. In this 2007 study, only 68% of surgeons reported using intraoperative radiographs for lumbar disk surgery. Groff et al17 reported on the results of a survey of neurosurgeons with regard to their experience with wrong-level lumbar surgery. Of 569 respondents, 175 (31.5%) reported performing surgery at the wrong lumbar level once; 72 (13.6%) performed surgery at the wrong lumbar level more than once; 53 (9.3%) per-

formed surgery on the wrong side once; and 6 (1.1%) performed surgery on the wrong side more than once. In 67.8% of cases in which wrong-level or wrong-side surgery was performed, the error was identified intraoperatively, and the correct surgery was executed. Mody et al7 also conducted a survey of neurosurgeons experience with regard to WLSS. The authors received 415 responses to more than 3,000 surveys sent to neurosurgeons (12% response rate). Fifty percent (207) of those surveyed reported performing one or more wrong-level operations during their career. There was a significant reduction in the annual risk for WLSS associated with increased duration of practice (P < 0.001). No significant difference was found in the reported WLSS rate for surgeons in academic versus private practice or for surgeons with higher annual surgical load. In a retrospective study of American Board of Orthopaedic Surgery candidates from 1999 to 2010, the number of wrong-site surgeries performed by candidates eligible for board certification was assessed.11 A total of 897 orthopaedic spine surgeons submitted 324,085 spinal procedures during the study period. Thirty-one surgeons (3.5%) reported a WSSS during their 6-month collection period, for an overall estimated WSSS rate of 0.041%. Of the 26 wrong-level spine procedures reported, 14 cases involved the lumbar spine, 2 involved the thoracic spine and 8 involved the cervical spine. Intraoperative radiographs were obtained in all cases. Misinterpretation of the radiograph by the surgeon was the most common reason given for wrong-level cervical and lumbar surgery. Minimally invasive and endoscopic spine surgery may also contribute to WLSS. Matsumoto et al15 conducted a survey of the members of the Japa-

nese Orthopaedic Society. Of 6,239 endoscopic spinal procedures performed in 2007, 6 wrong-level operations and 1 wrong-side operation were reported. We believe that unrecognized movement of the tubular retractor during minimally invasive procedures may contribute to intervention at the wrong spinal level.

Risk Factors
The overall strength of the data available to establish the risk factors for WSSS has been rated as low.3 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 patients family.2,3,7,11,14,17-20 WLSS has also been associated with failure to localize the correct vertebral level with an intraoperative radiograph.5 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.4,11

As stated previously, WSSS can have serious medical, legal, and emotional consequences. From a clinical standpoint, the pathologic process and the patients symptomatology are not addressed in the setting of WSSS. Incorrect-side or -level decompression will traumatize the paraspinal soft tissues, disrupt the osseoligamentous stabilizing structures, and produce epidural fibrosis. Unplanned


Journal of the American Academy of Orthopaedic Surgeons

Mark A. Palumbo, MD, et al

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. If not detected intraoperatively, WSSS will delay execution of the correct procedure and symptom resolution. Although many cases of WSSS go unreported, this complication can and often does result in legal action. Therefore, WSSS identified intraoperatively (with the correct procedure ultimately performed) must be distinguished from WSSS identified postoperatively in which the pathoanatomy is not addressed. These two situations may have different clinical outcomes; however, no studies have reported on the relative risk of subsequent litigation. Goodkin and Laska5 reported on data from 69 cases of WLSS from 1984 to 2000. Thirtyseven cases were settled; a plaintiff verdict was rendered in 18, and a defense verdict was rendered in 13. Indemnity payments ranged from $62,000 to $1,500,000. In addition to legal consequences, emotional and social harm often results from WSSS. Patients may suffer substantial despair and psychologic distress and may lose trust not only in the surgeon but possibly in all physicians. The responsible surgeon may experience embarrassment, guilt, and fear. The situation is often perceived as the physicians worst nightmare because of the impending personal, professional, and legal repercussions.21

mented with a surgeon-driven, patient-specific protocol.

Intraoperative Localization Principles

According to the American Academy of Orthopaedic Surgeons, Spinal surgery done at the wrong level can be prevented with an intraoperative x-ray that marks the exact vertebral level (site) of surgery.23 However, no consensus exists regarding the specific radiologic protocol, and considerable variability exists in the surgeons methodology for spinal segment localization.17 Radiographic localization is a critical step in performing spine surgery at the correct level. When the pathology is unclear based on the patients anatomy or a previous procedure, a radiograph can be obtained before the incision is made, with a radiopaque skin marker used to confirm appropriate incision placement. After dissection to the spinal column, radiographic imaging is performed with a metallic instrument attached to a fixed osseous structure. This radiograph should be compared to the analogous preoperative image to confirm the correct surgical site. Accurate radiographic identification of the correct vertebral level may pose a significant challenge even for the experienced spine surgeon. This is particularly true for spinal levels at a distance from the lumbosacral or craniocervical junction. In cases of difficult localization, the potential for misinterpretation can be reduced by obtaining another interpretation of the image by a second surgeon or a radiologist. It is important to note that obtaining a radiograph does not guarantee that surgery will be performed at the correct level. Limitations of intraoperative radiography include (1) image misinterpretation secondary to variant spinal anatomy and/or incorrect counting of the spinal level; (2) suboptimal image quality related to inadequate film exposure, body habitus, or the surgical

Preoperative Planning
For all nonemergent cases, a specific surgical plan should be established well in advance of the date of surgery. This requires the surgeon to analyze all relevant radiographic studies and to specify the procedure, laterality, and the exact vertebral level or levels to be addressed. Along with advanced neuroradiographic imaging, the surgeon should obtain specific plain radiographic views of the spine preoperatively; these views will be compared with the same views obtained intraoperatively for localization purposes during surgery. The planned surgical level or levels must be identified on plain radiographs after correlation with the magnetic resonance images and/or CT myelogram. The radiologists interpretation should never be used in isolation; images should be directly interpreted by the surgeon.22 The technical plan documented in the outpatient office record should be transferred accurately to the surgical consent and the hospital medical record. On the day of surgery, the surgeon should review all pertinent documentation (eg, office notes, surgical consent, history, physical examination) before proceeding with the JCAHO and/or NASS protocol. The neuroradiographic studies and plain radiographs should be displayed in the operating room throughout the procedure. Confirmation of the correct patient name and study date is mandatory. The level or levels and laterality of the pathoanatomy should be correlated with the patients symptoms and signs. It is useful to mark the intended surgical level or levels on the preoperative plain radiographs and to display a written surgical plan that can be referenced by all operating room personnel.

Strategies to Achieve Correct Site Surgery

To avoid WSSS, the JCAHO and NASS guidelines must be suppleMay 2013, Vol 21, No 5


Wrong-site Spine Surgery

Figure 1

Denitive identication of the surgical level achieved using a lateral radiograph of the spine. A, Intraoperative lateral radiograph of the cervical spine demonstrating the placement of a bent spinal needle in the C5-6 disk space for cervical localization. B, Intraoperative lateral radiograph of the cervical spine in a patient with a short neck. Note the incomplete imaging of C6, C7, and T1 on this view, which makes it inadequate for identifying lower spinal levels.

table; and (3) failure to recognize the absence of expected pathology at the surgical level.5,24

Cervical Spine Localization

In most cases, accurate localization of a cervical level can be achieved using a combination of anatomic landmarks and a lateral radiograph of the cervical spine. For the anterior cervical approach, palpation of the carotid tubercle on C6 can serve as a guide to the adjacent C5-6 and C6-7 disk spaces. Prominent ventral end plate osteophytes at or adjacent to the planned surgical level also can be used as a preliminary guide to the correct disk space or spaces. Although identification of osseous landmarks is useful, it should be viewed as a preliminary step in the localization process. A lateral radiograph of the spine should be obtained after the disk space is marked to definitively identify the correct surgical level. Methods to verify the correct level include

(1) placing a distractor pin in the vertebral body above or below the disk, (2) affixing a clamp to the anterior longitudinal ligament, or (3) placing a bent spinal needle into the selected disk space (Figure 1, A). Methods that do not penetrate the annulus can theoretically prevent iatrogenic injury to the disk when an unintended level is initially marked. Once the correct disk space is confirmed on imaging, electrocautery is used to mark the annulus. For a posterior approach, the large and often palpable C2 and T1 spinous processes can be used for preliminary localization in the upper and lower cervical spine, respectively. The endomorphic patient with a short neck poses a specific challenge to definitive radiographic localization (Figure 1, B). Although placing traction on the shoulders using tape can be helpful for visualizing the lower cervical levels, it may not be possible to obtain lateral images that are adequate for localiza-

tion purposes. During posterior surgery at the cervicothoracic junction, the challenge of localizing levels can often be overcome by obtaining an AP radiograph with a marker placed at the T1 spinous process. The first thoracic vertebra can be easily identified by its large lamina and transverse processes, which articulate with the first rib. An alternative approach involves attaching an instrument to a more cranial spinous process, which is visible on a lateral radiograph. Counting spinous processes downward to determine the correct spinal level is effective but requires additional exposure of upper cervical segments. Cervical anomalies, such as congenital fusion of vertebrae associated with Klippel-Feil syndrome, may lead to WLSS. A block vertebra at C2-C3 may lead the surgeon to mistake the C3 body for the C2 body. Identification of this abnormality on preoperative images and due diligence during surgery are required to avoid a wrong-level procedure.

Thoracic Localization
Thoracic spine pathology without associated radiologic abnormality (eg, thoracic disk herniation, epidural space-occupying lesion) requires special consideration. Preoperative MRI must include a sagittal view that spans from the sacrum to the thoracic level of interest. When MRI is contraindicated, a CT myelogram of the spine with enlarged AP and lateral scout radiographs and numbered vertebral levels should be obtained. The enlarged view of the sagittal magnetic resonance image or the scout radiographs must be available to the surgeon before and during surgery. Identification of the pathologic level on preoperative plain radiographs is a mandatory step in achieving accurate intraoperative localiza-


Journal of the American Academy of Orthopaedic Surgeons

Mark A. Palumbo, MD, et al

Figure 2

Imaging studies demonstrating thoracic counting error as a result of counting from C2 rather than counting from the sacrum. A, Sagittal T2-weighted magnetic resonance image demonstrating a lesion involving a verterbal body. When counted caudally from C2, the lesion is described as a T7 lesion. B, Sagittal CT scan of the spine in the same patient. When counting cephalad from the sacrum, the same lesion is described as a T8 lesion. (Reproduced with permission from Hsu W, Kretzer RM, Dorsi MJ, Gokaslan ZL: Strategies to avoid wrong-site surgery during spinal procedures. Neurosurg Focus 2011;31[4]:E1-5.)

tion. Preoperative AP and lateral long-cassette scoliosis radiographs are useful for identifying variation in the usual number of 12 rib-bearing thoracic vertebrae and 5 non-rib bearing lumbar vertebrae. If fulllength films of the entire spinal axis are not available, then large-cassette AP and lateral radiographs that span from the pelvis to the level of thoracic pathology typically will be adequate. The preoperative plain radiographs must be correlated to the
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screening neuroradiologic image to define the appropriate level before the day of surgery. The pathologic vertebral segment or segments should be identified on both AP and lateral projections by counting levels up from the sacrum based on the preoperative sagittal magnetic resonance image. To avoid counting error, the same preoperative localization method should be repeated at the time of surgery (Figure 2). A standard intraop-

erative counting method involves placement of a radiopaque marker at a fixed point in the thoracic spine and then counting up from the sacrum to the level of interest. If cassette size is limited, it may be necessary to obtain serial fluoroscopic or plain radiographic images, with markers placed at intervals spanning multiple vertebrae. Localization of the relevant level on an AP radiograph may be necessary for procedures performed with the patient in the decubitus position and when difficulty in obtaining a high-quality lateral radiograph is anticipated (eg, upper thoracic pathology, morbidly obese patient). Several methods to improve the accuracy of thoracic localization have been described, including the use of radiopaque skin markers,25 methylene blue dye injection,26 and oblique radiographs.27 Although these methods may be useful in select cases as an adjunct to standard radiographic methods, they do not guarantee correct localization. Skin markers cannot be relied on because the skin moves relative to fixed osseous structures during the positioning process. Methylene blue dye may be neurotoxic and should be injected only superficially; dye spread into the subcutaneous tissue layer can compromise precise identification of a spinal level. Oblique radiographic views avoid beam penetration through much of the torso and shoulder musculature and may aid the surgeon in visualizing the cervicothoracic junction. However, poor bone quality, nonprone patient positioning, and anatomic anomalies may make this strategy insufficient for prevention of localization errors. More invasive methods of ensuring accurate intraoperative localization have been proposed. Preoperative injection of barium-infused polymethyl methacrylate cement into a vertebral body is one such strategy.28 Another method of localization before surgical


Wrong-site Spine Surgery

Figure 3

Lateral radiographs of the spine demonstrating lumbar localization via three methods. A, Localization is performed via percutaneous placement of a spinal needle at the level of the L4 spinous process. Indigo carmine dye is then injected to mark the spinous process before the incision is made to aid in the approach. B, A clamp is placed on the L4 spinous process, indicating the correct level for decompression. C, Lumbar diskectomy localization is conrmed by inserting a Peneld 4 elevator within the L4-5 disk space to conrm the appropriate level of the performed diskectomy.

intervention involves placement of a radiopaque coil adjacent to the desired thoracic pedicle.29 A third alternative described by Upadhyaya et al30 consists of preoperative CT-guided fiducial screw placement in the thoracic spine. When MRI or localizing fluoroscopy is not obtainable, such as in cases of extreme obesity, CT-guided placement of a metallic bead within the posterior elements may be performed for spinal level localization. Concerns regarding these strategies include exposure of the patient to a second invasive procedure, potential complications associated with the supplemental localization technique, and additional financial cost.

Lumbosacral Localization
Although localization in the lumbar region typically is straightforward, two factors warrant heightened awareness. The first relates to the prevalence of monoradiculopathy,

which requires a unilateral decompressive procedure. As a supplement to the JCAHO and NASS protocols, the correct surgical side should be verified by directly questioning the patient in the operating room. The patients response is then correlated with the preoperative documentation of the laterality of symptoms and the pathoanatomy as identified on neuroradiologic imaging studies. The second factor is the presence of a lumbosacral transitional vertebra (LSTV), a relatively common congenital anomaly that may result in WLSS. The overall reported prevalence ranges from 4% to 35.6% in the general population.8,9,24,31 In the most common form of LSTV, the fifth lumbar segment shows signs of assimilation to the sacrum, a condition termed sacralization. Lumbarization refers to anomalous osseous morphology in which the first sacral vertebra shows signs

of transition to a lumbar configuration. These spinal abnormalities must be identified on preoperative plain radiographs to plan the intraoperative localization process. Consistent nomenclature referring to the last lumbar motion segment may assist in communication and documentation. Diligent review and correlation of the preoperative MRI (or CT myelogram) with the AP and lateral radiographs is especially important in the setting of variant lumbosacral anatomy. A logical protocol for intraoperative lumbosacral localization during a posterior approach involves the use of the iliac crest as a surface landmark to approximate the L4-5 disk space (Figure 3, A). A sterile, 18gauge 3.5-inch-long spinal needle is placed percutaneously at the approximated level of surgery. Preferably, the needle is embedded in a bony structure such as a spinous process.


Journal of the American Academy of Orthopaedic Surgeons

Mark A. Palumbo, MD, et al

A lateral radiograph of the spine provides precise localization of the incision based on the position of the needle relative to the pathologic spinal motion segment. Injection of indigo carmine dye to mark the relevant spinous process before creating the incision can be helpful. After dissection and exposure of the lamina, the vertebral level is definitively identified by obtaining a second lateral radiograph after a clamp is attached to the spinous process or a probe is placed within the interlaminar space (Figure 3, B). If the pathologic lesion is not obvious during the decompressive procedure, a final radiograph may be obtained with a radiopaque marker situated within the disk space (Figure 3, C). Marking the pedicle by placing a clamp on the appropriate transverse process may also be helpful in arthrodesis procedures.

cord.23 The patient and, when appropriate, the patients family should be notified of the incident. Discrete disclosure to patients and families assists in retaining their trust in the surgeon, decreases the likelihood of litigation, and initiates the healing process for both surgeon and patient.37 Hospital systems may have support systems in place for the surgeon, operating room staff, and the patient involved in the incident.21

studies. References 10, 20-23, 25, and 31 are level V expert opinion. References printed in bold type are those published within the past 5 years.
1. The Joint Commission: Summary data of sentinel events reviewed by the Joint Commission: December 31, 2012. Available at: http:// sentinel_event_statistics_quarterly. Accessed February 28, 2013. Ammerman JM, Ammerman MD: Wrong-sided surgery. J Neurosurg Spine 2008;9(1):105-106. Devine J, Chutkan N, Norvell DC, Dettori JR: Avoiding wrong site surgery: A systematic review. Spine (Phila Pa 1976) 2010;35(9 suppl):S28-S36. Fager CA: Malpractice issues in neurological surgery. Surg Neurol 2006; 65(4):416-421. Goodkin R, Laska LL: Wrong disc space level surgery: Medicolegal implications. Surg Neurol 2004;61(4):323-342. Hsu W, Kretzer RM, Dorsi MJ, Gokaslan ZL: Strategies to avoid wrongsite surgery during spinal procedures. Neurosurg Focus 2011;31(4):E5. Mody MG, Nourbakhsh A, Stahl DL, Gibbs M, Alfawareh M, Garges KJ: The prevalence of wrong level surgery among spine surgeons. Spine (Phila Pa 1976) 2008;33(2):194-198. Apazidis A, Ricart PA, Diefenbach CM, Spivak JM: The prevalence of transitional vertebrae in the lumbar spine. Spine J 2011;11(9):858-862. Harmon PH: Congenital and acquired anatomic variations, including degenerative changes of the lower lumbar spine; role in production of painful back and lower extremity syndromes. Clin Orthop Relat Res 1966; 44:171-186. North American Spine Society: Sign, Mark & X-ray (SMax): Prevent wrongsite surgery. Available at: http:// ClinicalCare/Smax/Default.aspx. Accessed February 28, 2013. James MA, Seiler JG III, Harrast JJ, Emery SE, Hurwitz S: The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery. J Bone Joint Surg Am 2012;94(1):e2(112). Kwaan MR, Studdert DM, Zinner MJ, Gawande AA: Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 2006;141(4):353-358. Barrios C, Ahmed M, Arrtegui J,



WSSS is a potentially devastating event for the patient and the surgeon. Despite major efforts aimed at prevention, wrong-site spinal operations continue to occur, with the potential for serious medical, personal, and legal repercussions. Systems-based prevention methods are effective in identifying the proper patient, the correct region of the spinal column, and the planned procedure. However, these standardized protocols cannot be relied upon to establish the correct vertebral level during the operation. 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. Thus, the JCAHO and NASS guidelines must be supplemented by a patient-specific protocol designed and implemented by the surgeon to ensure that the appropriate operation is performed at the correct site within the spinal column.



Intraoperative CT
Intraoperative CT is increasingly used to guide screw placement in the cervical,32 thoracic,33,34 and lumbosacral spine.35,36 Although this imaging modality appears to improve the accuracy of instrumentation placement,33,36 routine use of CT for vertebral level localization is not practical. If the surgeon anticipates a challenging localization process (secondary to anatomic anomaly or complex deformity), intraoperative CT may be appropriate. However, the potential benefit must be weighed against the financial cost and a significant increase in radiation exposure to the patient and surgical personnel.





Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, there are no level I studies. References 3 and 16 are level II studies. References 8, 13, 30, and 32-37 are level III studies. References 1, 2, 5, 7, 9, 11, 12, 14, 15, 17, 18, 24, and 26-29 are level IV


Procedure Following WSSS Identication

When WSSS does occur, the riskmanagement department of the hospital should be contacted immediately. The surgeon should accurately record the events in the medical reMay 2013, Vol 21, No 5




Wrong-site Spine Surgery

Bjrnsson A, Gillstrm P: Microsurgery versus standard removal of the herniated lumbar disc: A 3-year comparison in 150 cases. Acta Orthop Scand 1990;61(5): 399-403. 14. Jhawar BS, Mitsis D, Duggal N: Wrongsided and wrong-level neurosurgery: A national survey. J Neurosurg Spine 2007; 7(5):467-472. Matsumoto M, Hasegawa T, Ito M, et al: Incidence of complications associated with spinal endoscopic surgery: Nationwide survey in 2007 by the Committee on Spinal Endoscopic Surgical Skill Qualification of Japanese Orthopaedic Association. J Orthop Sci 2010;15(1):92-96. Ammerman JM, Ammerman MD, Dambrosia J, Ammerman BJ: A prospective evaluation of the role for intraoperative x-ray in lumbar discectomy: Predictors of incorrect level exposure. Surg Neurol 2006;66(5):470474. Groff MW, Heller JE, Potts EA, Mummaneni PV, Shaffrey CI, Smith JS: A survey-based study of wrong-level lumbar spine surgery: The scope of the problem and current practices in place to help avoid these errors. World Neurosurg 2012;April 2 [epub ahead of print]. A follow-up review of wrong-site surgery. Sentinel Event Alert 2001; 24:1-3. Patient safety first alert: Implementing a correct site surgery policy and procedure. AORN J 2002;76(5):785-788. Pheasant H: Sources of failure in laminectomies. Orthop Clin North Am 1975;6(1):319-329. Ring DC, Herndon JH, Meyer GS: Case records of The Massachusetts General Hospital: Case 34-2010. A 65-year-old woman with an incorrect operation on the left hand. N Engl J Med 2010; 363(20):1950-1957. 22. Young PM, Berquist TH, Bancroft LW, Peterson JJ: Complications of spinal instrumentation. Radiographics 2007; 27(3):775-789. American Academy of Orthopaedic Surgeons: Information statement: Wrong-site surgery. Available at: http:// PDFopen.cfm?page_url=http:// 1015.asp. Revised December 2008. Accessed February 28, 2013. Konin GP, Walz DM: Lumbosacral transitional vertebrae: Classification, imaging findings, and clinical relevance. AJNR Am J Neuroradiol 2010;31(10): 1778-1786. Rosahl SK, Gharabaghi A, Liebig T, Feste CD, Tatagiba M, Samii M: Skin markers for surgical planning for intradural lesions of the thoracic spine: Technical note. Surg Neurol 2002;58(5): 346-348. Paolini S, Ciappetta P, Missori P, Raco A, Delfini R: Spinous process marking: A reliable method for preoperative surface localization of intradural lesions of the high thoracic spine. Br J Neurosurg 2005;19(1):74-76. Singh H, Meyer SA, Hecht AC, Jenkins AL III: Novel fluoroscopic technique for localization at cervicothoracic levels. J Spinal Disord Tech 2009;22(8):615618. Hsu W, Sciubba DM, Sasson AD, et al: Intraoperative localization of thoracic spine level with preoperative percutaneous placement of intravertebral polymethylmethacrylate. J Spinal Disord Tech 2008;21(1):72-75. Binning MJ, Schmidt MH: Percutaneous placement of radiopaque markers at the pedicle of interest for preoperative localization of thoracic spine level. Spine (Phila Pa 1976) 2010;35(19):18211825. Upadhyaya CD, Wu JC, Chin CT, Balamurali G, Mummaneni PV: Avoidance of wrong-level thoracic spine surgery: Intraoperative localization with 34. preoperative percutaneous fiducial screw placement. J Neurosurg Spine 2012; 16(3):280-284. 31. OConnor JF, Cranley WR, McCarten KM, Radkowski MA: Radiographic manifestations of congenital anomalies of the spine. Radiol Clin North Am 1991;29(2):407-429. Hecht AC, Koehler SM, Laudone JC, Jenkins A, Qureshi S: Is intraoperative CT of posterior cervical spine instrumentation cost-effective and does it reduce complications? Clin Orthop Relat Res 2011;469(4):1035-1041. Ughwanogho E, Patel NM, Baldwin KD, Sampson NR, Flynn JM: Computed tomography-guided navigation of thoracic pedicle screws for adolescent idiopathic scoliosis results in more accurate placement and less screw removal. Spine (Phila Pa 1976) 2012; 37(8):E473-E478. Cui G, Wang Y, Kao TH, et al: Application of intraoperative computed tomography with or without navigation system in surgical correction of spinal deformity: A preliminary result of 59 consecutive human cases. Spine (Phila Pa 1976) 2012;37(10):891-900. Houten JK, Nasser R, Baxi N: Clinical assessment of percutaneous lumbar pedicle screw placement using the O-arm multidimensional surgical imaging system. Neurosurgery 2012;70(4):990995. Costa F, Cardia A, Ortolina A, Fabio G, Zerbi A, Fornari M: Spinal navigation: Standard preoperative versus intraoperative computed tomography data set acquisition for computerguidance system. Radiological and clinical study in 100 consecutive patients. Spine (Phila Pa 1976) 2011; 36(24):2094-2098. Kachalia A, Kaufman SR, Boothman R, et al: Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med 2010;153(4):213-221.






















Journal of the American Academy of Orthopaedic Surgeons