The medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the United States

Analysis of reasons for medical malpractice litigation due to anterior cervical discectomy and fusion

Background

Anterior cervical discectomy and fusions (ACDF) are among the most common cervical spine operations, with over 137,000 surgeries performed annually. Understanding reasons underlying malpractice pertaining to ACDF may inform physicians of practices to improve delivery of patient care and mitigate malpractice. The aim of our study was to analyze the causes and outcomes for lawsuits pertaining to ACDF.

Methods

The Westlaw Edge and Verdict Search databases were queried for malpractice claims utilizing the keywords "anterior cervical discectomy and fusion" and "ACDF". Inclusion criteria was based on relevance of case grievance(s) to ACDF. Data collected included date of case hearing, plaintiff demographics, defendant specialty, verdict ruling, location of filed claim, monetary award, and sustained injuries.

Results

Fifty cases were included in this study after excluding 1933 cases. Of the 50 cases, 34 (68%) resulted in a defendant outcome, 8 (16%) resulted in a plaintiff outcome, and 8 (16%) resulted in settlement. Plaintiff verdicts resulted in an average monetary payment of $9.70 million, while settlements resulted in an average payment of $2.06 million. Reasons for litigation were divided into 10 categories, most commonly improper postoperative management (20%), hardware failure (18%), intraoperative error (14%), off-label use of implants (14%), and insufficient informed consent (12%).

Conclusions

Malpractice claims due to ACDF are associated with higher frequencies of plaintiff verdicts and higher monetary costs compared to other spinal surgery procedures. There does not appear to be supporting evidence that spinal cord neuromonitoring is mandatory for ACDF procedures from a medicolegal standpoint.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis

INTRODUCTION

Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion.

METHOD

A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0).

RESULTS

25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries.

CONCLUSION

Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Assessing intraoperative pedicle screw placement accuracy using biplanar radiographs compared to three-dimensional imaging

To date, biplanar imaging (2D) has been the method of choice for pedicle screw (PS) positioning and verified for the anteroposterior view and (spinal midline) M-line method. In recent years, the use of intraoperative three-dimensional (3D) imaging has become available with the Gertzbein-Robbins system (GRS) to assess PS breach and positioning confirmation. The aim is to determine if 2D imaging is sufficient to assess PS position in comparison to advanced 3D imaging.Retrospective review of prospectively collected data from 204 consecutive adult patients who underwent posterior thoracic and lumbar instrumented fusion for degenerative spinal surgery by a single surgeon (2019-2022).Of the 204 patients, 187 (91.6%) had intraoperative images available for analysis. A total of 1044 PS implants were used; 922 (88.3%) were robotically placed. Postoperative CT scans were verified with M-line/GRS findings. Among 103 patients (50.5%) with a total of 362 screws, (34.7%) had postoperative CT, intraoperative 3D scan, and intraoperative 2D scan for analysis. Postoperative CT findings were consistent with all GRS findings, validating that 3D imaging was accurate. Screws (1%) were falsely verified by the M-line as 3D imaging confirmed false negative or positive findings.In our series, intraoperative 3D scan was as accurate as postoperative CT scan in assessing PS breach. A significant number of PS may be falsely read as accurate on 2D imaging, that is in fact inaccurate when assessed on 3D imaging. An intraoperative post-instrumentation 3D scan may be preferable to prevent postoperative recognition of a falsely verified screw on biplanar imaging.

Robotic-Assisted Surgery and Navigation in Deformity Surgery

Deformity surgery is advancing quickly with the use of three-dimensional navigation and robotics. In spinal fusion, the use of robotics improves screw placement accuracy and reduces radiation, complications, blood loss, and recovery time. Currently, there is limited evidence showing that robotics is better than traditional freehand techniques. Most studies favoring robotics are small and retrospective due to the novelty of the technology in deformity surgery. Using these systems can also be expensive and time-consuming. Surgeons should use these advancements as tools, but not rely on them to replace surgical experience, anatomy knowledge, and good judgment.

Let's think beyond the pedicle: A biomechanical study of a new conceptual extra pedicular screw and hook construct

Background

Transpedicular screws have proven the test of time, yet they are not devoid of complications. Many newer techniques such as 2 D and 3D fluoroscopy,O arm Navigation assisted surgery, robotic assisted surgery have come into existence to the increase precision in pedicle screw insertion. But, complications do occur in their presence. We propose an Extra pedicular screw and hook system (EPSH) system with similar biomechanical property, better safety profile and short learning curve compared to traditional pedicle screw.

Purpose

To Compare the pull out strength of Traditional Pedicle screw Vs Extra pedicular screw and hook system(EPSH).

Methods

Biomechanical testing was conducted according ASTM F543 guidelines to compare the pull-out strength of EPSH based construct and traditional pedicle screw construct. Six saw bone samples in each group considered. Screw of 5.5 mm diameter and length of 35 mm was used in both the groups. Pull out strength assessed by giving 5 mm/min axial load. The axial load Vs displacement of the screw were recorded and plotted. The maximum load required for screw failure is noted in both the group. Statistical analysis was done.

Results

The mean peak load of pedicle screw group was found to be 1670.9 ± 393.2 N with mean displacement at peak load was found to be 13.44 ± 1.7 mm and in EPSH group it was 1416.4 ± 341.4 N and 15.78 ± 3.9 mm respectively. A paired t-test showed no statistical difference(p < 0.05) between 2 groups.

Conclusion

EPSH has shown to have almost similar biomechanical property as that pedicle screw construct. With Addition of the hook, it provides an extra rotational stability as well. Being an extra-pedicular screw it has high safety profile and needs less expertise for insertion.

A Comparison of Percutaneous Pedicle Screw Accuracy Between Robotic Navigation and Novel Fluoroscopy-Based Instrument Tracking for Patients Undergoing Instrumented Thoracolumbar Surgery

BACKGROUND

The accuracy of pedicle screws placed with instrument tracking and robotic navigation are individually comparable or superior to placement using standard fluoroscopy, however head-to-head comparisons between these adjuncts in a similar surgical population have yet to be performed.

METHODS

Consecutive patients undergoing percutaneous thoracic and lumbosacral spinal instrumentation were retrospectively enrolled. Instrumentation was performed using either fluoroscopy-based instrument tracking system (TrackX, TrackX Technologies) or robotic-navigation (ExcelsiusGPS, Globus Medical). Postinstrumentation computed tomography scans were graded for breach according to the Gertzbein-Robbins scale, with "acceptable" screws deemed as Grade A or B and "unacceptable" screws deemed as Grades C through E. Accuracy data was compared between both instrumentation modalities.

RESULTS

Fifty-three patients, comprising a total of 250 screws (167 robot, 83 instrument tracking) were included. The overall accuracy between both modalities was similar, with 96.4% and 97.6% of screws with acceptable accuracy between instrument tracking and robotic navigation, respectively (I-squared 0.30, df = 1, P = 0.58). Between instrument tracking and robotic navigation, 92.8% and 95.8% of screws received Grade A, 3.6% and 1.8% a Grade B, 1.2% and 1.2% a Grade C, 1.2% and 0.6% a Grade D, and 1.2% and 0.6% a Grade E, respectively. The robot was abandoned intraoperatively in 2 cases due to unrecoverable registration inaccuracy or software failure, leading to abandonment of 8 potential screws (4.8%).

CONCLUSIONS

In a similar patient population, there is a similarly high degree of instrumentation accuracy between fluoroscopy-based instrument tracking and robotic navigation. There is a rare chance for screw breach with either surgical adjunct.

Augmented reality in minimally invasive spine surgery: early efficiency and complications of percutaneous pedicle screw instrumentation

BACKGROUND CONTEXT

Augmented reality (AR) employs an optical projection directly onto the user's retina, allowing complex image overlay on the natural visual field. In general, pedicle screw accuracy rates have improved with increasingly use of technology, with navigation-based instrumentation described as accurate in 89%-100% of cases. Emerging AR technology in spine surgery builds upon current spinal navigation to provide 3-dimensional imaging of the spine and powerfully reduce the impact of inherent ergonomic and efficiency difficulties.

PURPOSE

This publication describes the first known series of in vivo pedicle screws placed percutaneously using AR technology for MIS applications.

STUDY DESIGN / SETTING

After IRB approval, 3 senior surgeons at 2 institutions contributed cases from June, 2020 - March, 2022. 164 total MIS cases in which AR used for placement of percutaneous pedicle screw instrumentation with spinal navigation were identified prospectively.

PATIENT SAMPLE

155 (94.5%) were performed for degenerative pathology, 6 (3.6%) for tumor and 3 (1.8%) for spinal deformity.  These cases amounted to a total of 606 pedicle screws; 590 (97.3%) were placed in the lumbar spine, with 16 (2.7%) thoracic screws placed.

OUTCOME MEASURES

Patient demographics and surgical metrics including total posterior construct time (defined as time elapsed from preincision instrument registration to final screw placement), clinical complications and instrumentation revision rates were recorded in a secure and de-identified database.

METHODS

The AR system used features a wireless headset with transparent near-eye display which projects intra-operative 3D imaging directly onto the surgeon's retina. After patient positioning, 1 percuntaneous and 1 superficial reference marker are placed. Intra-operative CT data is processed to the headset and integrates into the surgeon's visual field creating a "see-through" 3D effect in addition to 2D standard navigation images. MIS pedicle screw placement is then carried out percutaneously through single line of sight using navigated instruments.

RESULTS

Time elapsed from registration and percutaneous approach to final screw placement averaged 3 minutes and 54 seconds per screw.  Analysis of the learning curve revealed similar surgical times in the early cases compared to the cases performed with more experience with the system.  No instrumentation was revised for clinical or radiographic complication at final available follow-up ranging from 6-24 months. A total of 3 screws (0.49%) were replaced intra-operatively. No clinical effects via radiculopathy or neurologic deficit postoperatively were noted.

CONCLUSIONS

This is the first report of the use of AR for placement of spinal pedicle screws using minimally invasive techniques.   This series of 164 cases confirmed efficiency and safety of screw placement with the inherent advantages of AR technologies over legacy enabling technologies.

Litigation involving sports-related spinal injuries: a comprehensive review of reported legal claims in the United States in the past 70 years

BACKGROUND CONTEXT

Sports-related spinal injuries can be catastrophic in nature. Athletes competing in collision sports (eg, football) may be particularly prone to injury given the high-impact nature of these activities. Due to the oftentimes profound impact of sports-related spinal injuries on health and quality-of-life, they are also associated with a substantial risk of litigation. However, no study to date has assessed litigation risks associated with sports-related spinal injuries. A better understanding of the risk factors surrounding these legal claims may provide insights into injury prevention and other strategies to minimize litigation risks. In addition, it may allow the spine surgeon to better recognize the health, socioeconomic, and legal challenges faced by this patient population.

PURPOSE

To provide a comprehensive assessment of reported legal claims involving sports-related spinal injuries, including a comparative analysis of legal outcomes between collision and non-collision sports. To discuss strategies to prevent sports-related spinal injuries and minimize litigation risks.

STUDY DESIGN/SETTING

Retrospective review.

PATIENT SAMPLE

Athletes experiencing spinal injuries during sports.

OUTCOME MEASURES

Outcomes included verdict outcome (defendant vs. plaintiff), legal claims, injuries sustained, clinical symptoms, and award payouts.

METHODS

The legal research database Westlaw Edge (Thomson Reuters) was queried for legal claims brought in the United States from 1950 to 2021 involving sports-related spinal injuries. Verdict or settlement outcomes were collected as well as award payouts, time to case closure, case year, and case location. Demographic data, including type of sport (ie collision vs. non-collision sport) and level of play were obtained. Legal claims, spinal injuries sustained, and clinical symptoms were also extracted. Furthermore, the nature of injury, injured spinal region, and treatment pursued were collected. Descriptive statistics were reported for all cases and independent-samples t-tests and chi-square tests were used to compare differences between collision and non-collision sports.

RESULTS

Of the 840 cases identified on initial search, 78 met our criteria for in-depth analysis. This yielded 62% (n=48) defendant verdicts, 32% (n=25) plaintiff verdicts, and 6% (n=5) settlements, with a median inflation-adjusted award of $780,000 (range: $5,480-$21,585,000) for all cases. The most common legal claim was negligent supervision (n=38, 46%), followed by premises liability (n=23, 28%), and workers' compensation/no fault litigation (n=10, 12%). The most common injuries sustained were vertebral fractures (n=34, 44%) followed by disc herniation (n=14, 18%). Most cases resulted in catastrophic neurological injury (n=37, 49%), either paraplegia (n=6, 8%) or quadriplegia (n=31, 41%), followed by chronic/refractory pain (n=32, 43%). Non-collision sport cases had a higher percentage of premises liability claims (41% vs. 11%, p=.006) and alleged chronic/refractory pain (53% vs. 28%, p=.04). Conversely, collision sport cases had a higher proportion of workers' compensation/no fault litigation (23% vs. 4%, p=.03) and cases involving disc herniation (29% vs. 9%, respectively; p=.04).

CONCLUSION

Sports-related spinal injuries are associated with multiple and complex health, socioeconomic, and legal consequences, with median inflation-adjusted award payouts nearing $800,000 per case. In our cohort, the most commonly cited legal claims were negligent supervision and premises liability, emphasizing the need for prevention guidelines for safe sports practice, especially in non-professional settings. Cases involving athletes participating in non-collision sports were significantly associated with claims citing chronic/refractory pain, highlighting the importance of long-term care in severely injured athletes.

Why are spine surgeons sued, and with what outcomes?

Background

Why are spine surgeons sued, how successfully, and for how much? Typical bases for spinal medicolegal suits have included; the failure to timely diagnose and treat, surgical negligence, (i.e. especially resulting in significant neurological deficits), and the lack of informed consent. We reviewed 17 medicolegal spinal articles looking for additional reasons for suits, along with identifying other factors contributing to defense verdicts, plaintiffs' verdicts, or settlements.

Methods

After confirming the same three most likely causes of medicolegal suits, other factors leading to such suits included; the lack of patient access to surgeons postoperatively, poor postoperative management (i.e. contributing to new postoperative neurological deficits), failure to communicate between specialists/surgeons perioperatively, and failure to brace.

Results

Critical factors leading to more plaintiffs' verdicts and settlements along with higher payouts for both included new severe and/or catastrophic postoperative neurological deficits. Conversely, defense verdicts were more likely for those with less severe new and/or residual injuries. The total number of plaintiffs' verdicts ranged from 17-35.2%, settlements, from 8.3-37%, and defense verdicts from 27.7-75%.

Conclusion

The three most frequent bases for spinal medicolegal suits continue to include; failure to timely diagnose/treat, surgical negligence, and lack of informed consent. Here, we identified the following additional causes of such suits; the lack of patient access to surgeons perioperatively, poor postoperative management, lack of specialist/surgeon communication, and failure to brace. Further, more plaintiffs' verdicts or settlements and greater respective payouts were observed for those with new and/or more severe/catastrophic deficits, while more defense verdicts were typically rendered for patients with lesser new neurological injuries.

Malpractice litigation in elective lumbar spinal fusion: a comprehensive review of reported legal claims in the U.S. in the past 50 years

BACKGROUND CONTEXT

In the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims.

PURPOSE

To provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF.

STUDY DESIGN/SETTING

A retrospective review.

PATIENT SAMPLE

Patients undergoing elective lumbar spinal fusion surgery.

OUTCOME MEASURES

The primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts.

METHODS

The Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award.

RESULTS

A total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850-$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800-$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches.

CONCLUSION

The results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF.