The 'nightmare' of wrong level in spine surgery: a critical appraisal
© Irace and Usai et al.; licensee BioMed Central Ltd. 2012
Received: 25 April 2012
Accepted: 15 May 2012
Published: 19 June 2012
The recent article published in the Journal by Lindley and colleagues (Patient Saf. Surg. 2011, 5:33) reported the successful surgical treatment of a persistent thoracic pain following a T7-8 microdiscectomy, truly performed at the ‘level immediately above’. The wrong level in spine surgery is a multi-factorial matter and several strategies have been designed and adopted to try decreasing its occurrence. We think that three of these factors are crucial: global strategy, attention, precision in level identification; and the actors we identified are the surgeon, the assistant nurse and the (neuro)radiologist respectively. Basing upon our experience, the role of the radiologist pre- and intraoperatively and the importance of the assistant nurse are briefly described.
In their recent article Lindley and Colleagues reported the successful surgical treatment of a persistent thoracic pain following a T7-8 microdiscectomy, truly performed at the ‘level immediately above’ .
First of all we greatly appreciated the lucid and meticulous management of such a case, which is peculiar because of its unusual anatomy and the history of a previous surgery at the same level; although it’s beyond the scope of this letter, probably we’d have opted for a repeat standard microdiscectomy at the correct level without attempting a posterior fusion, even though a concomitant rib fracture had been diagnosed preoperatively. Then, the attention paid to those medico-legal implications, which are deeply and insidiously linked to this case, is well deduced: the elucidation of the rarity of the thoracic spine anatomy of this patient is reported in a so detailed manner, that this case report is not only scientifically interesting, but it may also result as a powerful defence of those surgeons who performed the previous discectomy. Basing upon our experience in the matter of wrong level in spine surgery we wish to add some observations.
Team working: the spine surgeon and the (neuro)radiologist
Lindley and coauthors ‘recommend working closely with radiology colleagues’ and support ‘weekly radiology conferences…to assist with preoperative planning’ . We do agree with them concerning this team work: in addition, we consider the presence of the (neuro)radiologist in the operating theatre, or the remote interpretation of neuroimaging he can provide, really helpful for different reasons. Patient’s local conditions such as scoliosis, obesity, coexistence of internal metallic instrumentation easily obscure the radiographic appearance; the radiologist is the one who can correctly extricate among all different ‘greys’. Moreover the radiologist is free from surgery’s stressing pressure, as on the contrary the surgeon is: therefore he can provide a correct, illuminating and ultimate interpretation of intraoperative radiographic images (or ask for repeating it, if required) stressless. Lindley and Colleagues raise another crucial point of interest: the adoption of a common system to identify spinal pathological levels . A common system for level identification would be ideal in theory, but its practical application is rather problematic; our experience, as Italian regional and extra-regional referral center for spine diseases, showed us that patients coming to our attention, have received multiple neuroimaging reports, often conflicting one another. This condition is further blurred by the utilization of different, often confounding, terms to describe anatomical variations: ‘vestigial’, ‘rudimental’, ‘partial lumbarization or sacralization’, ‘last useful disc space’, variously mixed; to mitigate further confusion our strategy, both at the moment of compilation of medical charts and when describing surgical report, is to call the pathological (operated!) spine level exactly as the main neuroimaging report really does.
The nightmare of the wrong-level: how to avoid it
Concerning protocols adopted to avoid a wrong-level spinal operation, in addition to the ‘Sign, Mark and Xray (or SMaX) Program’  and the ‘JCAHO Protocol’  reported by the Authors, we wish to mention two more strategies (although not ‘national’, they received recent wide scientific attention): the ‘ABCD pause’  and the IRACE (Intraoperative Radiograph And Confirming Exclamation) method . If we compare all these strategies, we can observe that concerning the ‘SMaX Program’, our method seems more detailed and integrated because of the subsequent oral confirmation. The ‘JCAHO Protocol’ appears effective when applied to other fields of surgery, but it is less specific than the ‘IRACE method’ when used in lumbar spine surgery. The ‘ABCD pause’ does not identify the single person dedicated to the oral check; moreover the time-out does not address the problem of level error which may derive from incorrect direction of dissection during microsurgery. Although the attention paid by Lindley and Coll. was directed obviously to avoidance of wrong site surgery at the thoracic region, which indeed may be considered a pure surgical problem, other factors identified as crucial to decrease the rate of wrong level spinal (usually lumbar) operations must be remembered once again. Fatigue, sense of inferiority, external forces pressing the whole surgical team to complete a crowded operative session quickly, or a mixture of them, represent an explosive cocktail; and this is even more true, if you consider the current occurrence of repeat lumbar spine operations, strongly resembling one another, scheduled on the same day: such a scenario is not so dissimilar from an assembly line, which implies a high potential for gross error .
- Lindley EM: Unusual spine anatomy contributing to wrong level spine surgery: a case report and recommendations for decreasing the risk of preventable ‘never events’. Patient Safety in Surgery. 2011, 5: 33-10.1186/1754-9493-5-33.PubMed CentralView ArticlePubMedGoogle Scholar
- Wong DA, Watters WC: To err is human: quality and safety issues in spine care. Spine. 2007, 32 (Suppl 11): S2-S8.View ArticlePubMedGoogle Scholar
- Joint Commission on the Accreditation of Healthcare Organizations (USA): Universal Protocol. 2004,http://www.jointcommission.org/PatientSafety/NationalPatientSafety-Goals/04_npsgs.htm,
- Jhawar BS, Mitsis D, Duggal N: Wrong-sided and wrong-level neurosurgery: a national survey. J Neurosurg Spine. 2007, 7: 467-472. 10.3171/SPI-07/11/467.View ArticlePubMedGoogle Scholar
- Irace C, Corona C: How to avoid wrong-level and wrong-side errors in lumbar microdiscectomy. J Neurosurg Spine. 2010, 12: 660-665. 10.3171/2009.12.SPINE09627.View ArticlePubMedGoogle Scholar
- Irace C, Giannachi L, Usai S, Corona C: Wrong-sided surgery. J Neurosurg Spine. 2008, 9: 107-108. 10.3171/SPI/2008/9/7/107. letterView ArticlePubMedGoogle Scholar
- Stahel PF, Sabel AL, Victoroff MS: Wrong site and wrong patient procedures in the Universal Protocol era. Analysis of a prospective database of physicians self-reported occurrences. Arch Surg. 2010, 145: 978-984. 10.1001/archsurg.2010.185.View ArticlePubMedGoogle Scholar
- Matsumoto M, Hasegawa T, Ito M: 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: 92-96. 10.1007/s00776-009-1428-6.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.