Unusual spine anatomy contributing to wrong level spine surgery: a case report and recommendations for decreasing the risk of preventable 'never events'

The utility of intraoperative ultrasonography for spinal cord surgery

OBJECTIVES

Intraoperative ultrasonography (IOUS) offers the advantage of providing real-time imaging features, yet it is not generally used. This study aims to discuss the benefits of utilizing IOUS in spinal cord surgery and review related literature.

MATERIALS AND METHODS

Patients who underwent spinal cord surgery utilizing IOUS at a single institution were retrospectively collected and analyzed to evaluate the benefits derived from the use of IOUS.

RESULTS

A total of 43 consecutive patients were analyzed. Schwannoma was the most common tumor (35%), followed by cavernous angioma (23%) and ependymoma (16%). IOUS confirmed tumor extent and location before dura opening in 42 patients (97.7%). It was particularly helpful for myelotomy in deep-seated intramedullary lesions to minimize neural injury in 13 patients (31.0% of 42 patients). IOUS also detected residual or hidden lesions in 3 patients (7.0%) and verified the absence of hematoma post-tumor removal in 23 patients (53.5%). In 3 patients (7.0%), confirming no intradural lesions after removing extradural tumors avoided additional dural incisions. IOUS identified surrounding blood vessels and detected dural defects in one patient (2.3%) respectively.

CONCLUSIONS

The IOUS can be a valuable tool for spinal cord surgery in identifying the exact location of the pathologic lesions, confirming the completeness of surgery, and minimizing the risk of neural and vascular injury in a real-time fashion.

Evaluating compliance with the best practice guidelines for wrong-level surgery prevention in high-risk pediatric spine surgery

PURPOSE

In 2018, Best Practice Guidelines (BPGs) were published for preventing wrong-level surgery in pediatric spinal deformity, but successful implementation has not been established. The purpose of this study was to evaluate BPG compliance 5 years after publication. We hypothesized higher compliance among BPG authors and among surgeons with more experience, higher caseload, and awareness of the BPGs.

METHODS

We queried North American and European surgeons, authors and nonauthors, and members of pediatric spinal study groups on adherence to BPGs using an anonymous survey consisting of 18 Likert scale questions. Respondents provided years in practice, yearly caseload, and guideline awareness. Mean compliance scores (MCS) were developed by correlating Likert responses with MCS scores ("None of the time" = no compliance = MCS 0, "Sometimes" = weak to moderate = MCS 1, "Most of the time" = high = MCS 2, and "All the time" = perfect = MCS 3).

RESULTS

Of the 134 respondents, 81.5% reported high or perfect compliance. Average MCS for all guidelines was 2.4 ± 0.4. North American and European surgeons showed no compliance differences (2.4 vs. 2.3, p = 0.07). Authors and nonauthors showed significantly different compliance scores (2.8 vs 2.4, p < 0.001), as did surgeons with and without knowledge of the BPGs (2.5 vs 2.2, p < 0.001). BPG awareness and compliance showed a moderate positive correlation (r = 0.48, p < 0.001), with non-significant associations between compliance and both years in practice (r = 0.41, p = 0.64) and yearly caseload (r = 0.02, p = 0.87).

CONCLUSION

Surgeons reported high or perfect compliance 81.5% of the time with BPGs for preventing wrong-level surgery. Authorship and BPG awareness showed increased compliance. Location, study group membership, years in practice, and yearly caseload did not affect compliance.

LEVEL OF EVIDENCE

Level V-expert opinion.

Variations in the Number of Vertebrae, Prevalence of Lumbosacral Transitional Vertebra and Prevalence of Cervical Rib Among Surgical Patients With Adolescent Idiopathic Scoliosis: An Analysis of 998 Radiographs

STUDY DESIGN

Retrospective Study.

OBJECTIVE

This study aims to investigate variation in the number of thoracic and lumbar vertebrae, the prevalence of lumbosacral transitional vertebra (LSTV) and the prevalence of cervical ribs among surgical patients with adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Due to variation in the number of thoracic or lumbar vertebrae, inaccurate identification of vertebral levels has been found to be a contributory factor to wrong-level surgery.

METHODS

This was a retrospective study on AIS patients who underwent posterior spinal fusion. Demographic and anthropometric data (age, gender, height, weight, and body mass index), radiographic data (Lenke curve type, pre-operative Cobb angle, vertebra numbering of cervical, thoracic, and lumbar spine, presence of LSTV based on the Castellvi classification and the presence of cervical ribs) and clinical data were collected. Data were analysed and reported with mean and standard deviation for quantitative parameters and number and percentage for qualitative parameters. Multinomial logistic regression analyses were performed to identify factors associated with the outcomes of interest.

RESULTS

A total of 998 patients met inclusion criteria, of which 135 (13.5%) were males and 863 (86.5%) were females. The vertebrae number varied between 23 to 25 total vertebrae with 24 vertebrae considered as the typical number of vertebrae. The prevalence of atypical number of vertebrae (23 or 25) was 9.8% (98 patients). We found a total of 7 different variations in number of cervical, thoracic, and lumbar vertebrae (7C11T5L, 7C12T4L, 7C11T6L, 7C12T5L, 7C13T4L, 7C12T6L, and 7C13T5L) with 7C12T5L considered as the typical vertebrae variation. The total prevalence of patients with atypical vertebrae variation was 15.5% (155 patients). Cervical ribs were found in 2 (0.2%) patients while LSTV were found in 250 (25.1%) of patients. The odds of 13 thoracic vertebrae were higher in males (OR 5.17; 95% CI: 1.25, 21.39) and the odds of 6 lumbar vertebrae were higher in LSTV (OR 3.93; 95% CI: 2.58, 6.00).

CONCLUSION

In this series, we identified a total of 7 different variations in the number of cervical, thoracic, and lumbar vertebrae. The total prevalence of patients with atypical vertebrae variation was 15.5%. LSTV was found in 25.1% of the cohort. It is important to ascertain atypical vertebrae variations rather than the absolute number of vertebrae because variants such as 7C11T6L and 7C13T4L may still have typical numbers of vertebrae in total. However, due to the differences in the number of morphologically thoracic and lumbar vetrebrae, there may still be a risk of inaccurate identification.

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis

BACKGROUND

Never events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?

METHODS

For this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.

RESULTS

Our analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as 'wholly preventable'. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).

CONCLUSIONS

To improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

Intraoperative practices to prevent wrong-level spine surgery: a survey among 105 spine surgeons in the United Kingdom

Background

Current literature suggests that wrong-level spine surgery is relatively common with far-reaching consequences. This study aims to assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for correct level verification.

Methods

To assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for level verification. The authors hypothesise the absence of a standardised technique used across spine surgeons in the UK. Practices amongst respondents will be ascertained via an electronic questionnaire designed to evaluate current practices of spinal surgeons whom are members of the British Association of Spinal Surgeons (BASS). The study data will include key information such as; the level of surgical experience, specific techniques used to perform level checks for each procedure and prior involvement with wrong-level spine surgery. Responses were collected over the period of 1 month with a reminder sent 2 weeks prior to closure of the survey. The data were collated and descriptive analyses performed on multiple-choice question answers and common themes established from free text answers.

Results

A total of 27% (n = 105/383) members responded. The vast majority had greater than 10 years’ experience. Intraoperative practices varied greatly with varying practices present for cervical, thoracic and lumbar level surgery. Only 38% (n = 40) of respondents re-checked the level intra-operatively, prior to instrumentation. Of the respondents 47.5% (n = 29/61) of surgeons had been involved in wrong level spinal surgery.

Conclusion

This study highlights the varying practices amongst spinal surgeons and suggests root cause for wrong-level spine surgery; where the level identified pre-incision was subsequently not the level exposed. We describe a novel safety-check adopted at our institute using concepts and lessons learnt from the WHO Checklist.

Never events in orthopaedics: A nationwide data analysis and guidance on preventative measures

BACKGROUND

Never Events (NE) are serious clinical incidents that are wholly preventable if appropriate institutional safeguards are in place and followed. They are often used as a surrogate of the quality of healthcare delivered by an institution. Most NEs are surgical and orthopaedic surgery is one of the most involved specialties.

OBJECTIVE

The aim of this study was to identify common NE themes associated with orthopaedics within the National Health Service (NHS) of England.

METHOD

We conducted an observational study analysing the annual NE data published by the NHS England from 2012 to 2020 to collate all orthopaedic surgery-related NE and construct relevant recurring themes.

RESULTS

We identified 460 orthopaedic NE out of a total of 3247 (14.16%) reported NE to NHS England. There were 206 Wrong implants/prostheses under 8 different themes. Wrong hip and knee prosthesis were the commonest "wrong implants" (n = 94; 45.63% and n = 91; 44.17% respectively). There were 197 "Wrong-site surgery" incidents in 22 different themes. The commonest of these was the laterality problems accounting for 64 (32.48%) incidents followed by 63 (31.97%) incidents of wrong spinal level interventions. There were 18 (9.13%) incidents of intervention on the wrong patients and 17 (8.62%) wrong incisions. Retained pieces of instruments were the commonest retained foreign body with 15 (26.13%) incidents. The next categories were retained drill parts and retained instruments with 13 (22.80%) incidents each.

CONCLUSION

We identified 47 different themes of NE specific to orthopaedic surgery. Awareness of these themes would help in their prevention. Site marking can be challenging in the presence of cast and on operating on the digits and spine. Addition of a Real-time intra-operative implant scan to the National Joint Registry can avoid wrong implant selection while Fiducial markers, intraoperative imaging, O-arm navigation, and second time-out could help prevent wrong level spinal surgery.

Variations in the Number of Thoracic and Lumbar Vertebrae in Patients With Adolescent Idiopathic Scoliosis: A Retrospective, Observational Study

BACKGROUND

Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve.

METHODS

Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients' gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae.

RESULTS

Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae.

CONCLUSIONS

There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient's preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS.

Anatomical Variations That Can Lead to Spine Surgery at The Wrong Level: Part II Thoracic Spine

Spine surgery at the wrong level is a detrimental ordeal for both surgeon and patient, and it falls under the wrong-site surgery sentinel events reporting system. While there are several methods designed to limit the incidence of these events, they continue to occur and can result in significant morbidity for the patient and malpractice lawsuits for the surgeon. In thoracic spine, numerous risk factors influence the development of this misadventure. These include anatomical variations such as transitional vertebrae, rib variants, hemivertebra, and block/fused vertebrae as well as patient characteristics, such as tumors, infections, previous thoracic spine surgery, obesity, and osteoporosis. An extensive literature search of the PubMed database up to 2019 was completed on each of the anatomical entities and their influence on developing thoracic spine surgery at the wrong level, taking into consideration patient’s individual factors. A reliable protocol and effective techniques were described to prevent this error. In addition, the surgeon should collaborate with radiologists, particularly in challenging cases. A thorough understanding of the surgical anatomy and its variants coupled with patients characteristic is crucial for maximal patient benefit and avoidance of thoracic spine surgery at the wrong level.

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part I, Cervical Spine

Spine surgery at the wrong level is an adversity that many spine surgeons will encounter in their career, and it falls under the wrong-site surgery sentinel events reporting system. The cervical spine is the second most common location in the spine at which surgery is performed at the wrong level. Anatomical variations of the cervical spine are one of the most important incriminating risk factors. These anomalies include craniocervical junction abnormalities, cervical ribs, hemivertebrae, and block/fused vertebrae. In addition, patient characteristics, such as tumors, infection, previous cervical spine surgery, obesity, and osteoporosis, play an important role in the development of cervical surgery at the wrong level. These were described, and several effective techniques to prevent this error were provided. A thorough review of the English-language literature was performed in the database PubMed between 1981 and 2019 to review and summarize these risk factors. Compulsive attention to these factors is essential to ensure patient safety. Therefore, the surgeon must carefully review the patient's anatomy and characteristics through imaging and collaborate with radiologists to reduce the likelihood of performing cervical spine surgery at the wrong level.

Wrong Site Spine Surgery in the Veterans Administration

STUDY DESIGN

Basic descriptive analysis was performed for the incident characteristics of wrong level spinal surgery in the Veterans Health Administration (VHA).

OBJECTIVE

To determine the frequency of reported occurrence of incorrect spine level surgery in the VHA, causal factors for the events, and propose solutions to the issue.

SUMMARY OF BACKGROUND DATA

Wrong site surgery is one of the most common events reported to The Joint Commission. It has been reported that 50% of spine surgeons experience at least 1 wrong site surgery in their career, with events leading to signficant harm to patients.

MATERIALS AND METHODS

We examined incorrect level spine surgery adverse events reported to the VHA National Center for Patient Safety (NCPS) from 2000 to 2017. A rate of wrong site spine surgery was determined by dividing the number of wrong site cases by the total number of spine surgeries during the study period. Similarly, a rate of wrong site surgery by orthopedist and neurosurgeons was calculated.

RESULTS

There were 32 reported cases of wrong site spine surgery between 2000 and 2017. Fourteen cases involved the cervical region, 13 the lumbar region, and 5 the thoracic region. The majority of the root causes (69% or 48 of 69 root causes) fell into 2 broad categories: problems with the radiograph or problems with the intraoperative marker. These were not mutually exclusive and several root cause analyses involved >1 of these issues.

CONCLUSIONS

Wrong level surgery of the spine is a significant safety issue facing the field that continues to occur despite surgical teams following guidelines. As poor radiograph quality and interpretability were the most common root causes of these events, interventions aimed at optimizing image quality and accurate interpretation would be a logical first action.

Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity

STUDY DESIGN

Consensus-building using the Delphi and nominal group technique.

OBJECTIVE

To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery.

SUMMARY OF BACKGROUND DATA

Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed.

METHODS

The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting.

RESULTS

Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants.

CONCLUSION

We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery.

LEVEL OF EVIDENCE

Level V.

Accuracy and evaluation of irradiation of novel localization devices with unique three-dimensional structures in microendoscopic spine surgery

BACKGROUND

Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure.

PURPOSE

To evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery.

STUDY DESIGN

This was a retrospective cohort study.

METHODS

In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope.

RESULTS

Eight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10-1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1-7 s).

CONCLUSIONS

Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.

Abnormal rib count in scoliosis surgery: impact on the reporting of spinal fusion levels

PURPOSE

Variation in rib numbering has been noted in adolescent idiopathic scoliosis (AIS), but its effect on the reporting of fusion levels has not been studied. We hypothesized that vertebral numbering variations can lead to differing documentation of fusion levels.

METHODS

We examined the radiographs of 161 surgical AIS patients and 179 control patients without scoliosis. For AIS patients, the operative report of fusion levels was compared to conventional vertebral labeling from the first thoracic level and proceeding caudal. We defined normal counts as 12 thoracic (rib-bearing) and five lumbar (non-rib-bearing) vertebrae. We compared our counts with data from 181 anatomic specimens.

RESULTS

Among AIS patients, 22 (14 %) had an abnormal number of ribs and 29 (18 %) had either abnormal rib or lumbar count. In 12/29 (41 %) patients, the operative report differed from conventional labeling by one level, versus 3/132 (2 %) patients with normal numbering (p < 0.001). However, there were no cases seen of wrong fusion levels based on curve pattern. Among controls, 11 % had abnormal rib count (p = 0.41) compared to the rate in AIS. Anatomic specimen data did not differ in abnormal rib count (p = 1.0) or thoracolumbar pattern (p = 0.59).

CONCLUSIONS

The rate of numerical variations in the thoracolumbar vertebrae of AIS patients is equivalent to that in the general population. When variations in rib count are present, differences in numbering levels can occur. In the treatment of scoliosis, no wrong fusion levels were noted. However, for both scoliosis patients and the general population, we suggest adherence to conventional labeling to enhance clarity.

The tenth year of the “Universal Protocol”: are our patients safer today?

The “Universal Protocol” (UP) was launched as a regulatory compliance standard by the Joint Commission on 1st July 1 2004, with the primary intent of reducing the occurrence of wrong-site and wrong-patient surgery. As we’re heading into the tenth year of the UP implementation in the United States, it is time for critical assessment of the protocol’s impact on patient safety related to the incidence of preventable never-events. This article opens the debate on the potential shortcomings and pitfalls of the UP, and provides recommendations on how to circumvent specific inherent vulnerabilities of this widely established patient safety protocol.

Patient safety in spine surgery: regarding the wrong-site surgery

Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your site program by the American Academy of Orthopedic Surgeon, the sign, mark and X-ray program by the North American Spine Society, and the Universal Protocol program by the Joint Commission, the incidence of wrong-site surgery has not decreased. To prevent wrong-site surgery in spine surgeries, the spine surgeons must put patient safety first, complying with the hospital policies regarding patient safety. In the operating rooms, the surgeons need to do their best to level the hierarchy, enabling all to speak up if any patient safety concerns are noted. Changing the operating room culture is the essential part of the patient safety concerning spine surgery.

The 'nightmare' of wrong level in spine surgery: a critical appraisal

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.