Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part III Lumbosacral Spine

Frequency of Coexistent Spinal Segment Variants: Retrospective Analysis in Asymptomatic Young Adults

BACKGROUND AND PURPOSE

Spinal segment variants are highly prevalent and can potentially lead to incorrect spinal enumeration and, consequently, interventions or surgeries at the wrong vertebral levels. Our aim was to assess the prevalence of spinal segment variants and to study the potential association among these variants in a population without histories of spine symptoms.

MATERIALS AND METHODS

Consecutive computed tomography exams of 450 young adults originally evaluated for non-spinal conditions and without a history of spinal diseases from a single institution. In addition to using descriptive statistics for reporting frequencies of spinal segment variants, the association between these variants was studied by calculating odds ratios and their 95% confidence interval. Consecutive CT exams were evaluated to determine the total number of presacral segments, presence of cervical rib, thoracolumbar transitional vertebra, iliolumbar ligament, and lumbosacral transitional vertebra.

RESULTS

The spinal segment distribution variants (an atypical number of presacral segments or an atypical distribution of thoracolumbar vertebrae), cervical rib, thoracolumbar transitional vertebra, and lumbosacral transitional vertebra were reported in 23.8%, 4.2%, 15.3%, and 26.4% of cases in our study population. The presence of a cervical rib or a thoracolumbar transitional vertebra was associated with concurrent lumbosacral transitional vertebra (OR = 3.28; 95% CI, 1.29-8.47 and 1.87; 95% CI, 1.08-3.20, respectively). The inability to visualize the iliolumbar ligament was also associated with the presence of cervical ribs (OR = 3.06; 95% CI, 1.18-7.80).

CONCLUSIONS

In a population of asymptomatic young adults, spinal segment variants are both highly prevalent with a high rate of coexistence. When a spinal segment variant (eg, transitional vertebra) is diagnosed, additional imaging might be considered for accurate spine enumeration before interventions or operations.

Applications of artificial intelligence in orthopaedic surgery

The practice of medicine is rapidly transforming as a result of technological breakthroughs. Artificial intelligence (AI) systems are becoming more and more relevant in medicine and orthopaedic surgery as a result of the nearly exponential growth in computer processing power, cloud based computing, and development, and refining of medical-task specific software algorithms. Because of the extensive role of technologies such as medical imaging that bring high sensitivity, specificity, and positive/negative prognostic value to management of orthopaedic disorders, the field is particularly ripe for the application of machine-based integration of imaging studies, among other applications. Through this review, we seek to promote awareness in the orthopaedics community of the current accomplishments and projected uses of AI and ML as described in the literature. We summarize the current state of the art in the use of ML and AI in five key orthopaedic disciplines: joint reconstruction, spine, orthopaedic oncology, trauma, and sports medicine.

Clinical Anatomy and Medical Malpractice-A Narrative Review with Methodological Implications

Anatomical issues are intrinsically included in medico-legal methodology, however, higher awareness would be needed about the relevance of anatomy in addressing medico-legal questions in clinical/surgical contexts. Forensic Clinical Anatomy has been defined as "the practical application of Clinical Anatomy to the ascertainment and evaluation of medico-legal problems". The so-called individual anatomy (normal anatomy, anatomical variations, or anatomical modifications due to development, aging, para-physiological conditions, diseases, or surgery) may acquire specific relevance in medico-legal ascertainment and evaluation of cases of supposed medical malpractice. Here, we reviewed the literature on the relationships between anatomy, clinics/surgery, and legal medicine. Some methodological considerations were also proposed concerning the following issues: (1) relevant aspects of individual anatomy may arise from the application of methods of ascertainment, and they may be furtherly ascertained through specific anatomical methodology; (2) data about individual anatomy may help in the objective application of the criteria of evaluation (physio-pathological pathway, identification-evaluation of errors, causal value, damage estimation) and in final judgment about medical responsibility/liability. Awareness of the relevance of individual anatomy (risk of iatrogenic lesions, need for preoperative diagnostic procedures) should be one of the principles guiding the clinician; medico-legal analyses can also take advantage of its contribution in terms of ascertainment/evaluation.

Sacralization of Coccygeal Vertebra: A Descriptive Observational Study in Bangladesh

Background: In the sacrococcygeal region, anatomical variation is due to the sacralization of the coccygeal vertebra, which is the due union of/fusion of the fifth sacral with the first coccygeal vertebra of five couples of sacral foramina under-detected or asymptomatic beyond radiological assessment. That is why it is challenging to know the cause of coccydynia, caudal block failure, the difficult second stage of labor, and perineal tears. The present study aims to improve knowledge about the anatomical variation of sacralization of the coccygeal vertebra. Additionally, to find the prevalence of sacralization of coccygeal vertebra in Sylhet, Bangladesh.

Methods: This study was performed on 60 parched, totally calcified, typical sacra of mature-age individuals of undetermined sexes, fulfilling the inclusion criteria from the bone bank of the osteology museum of the Department of Anatomy, Sylhet MAG Osmani Medical College, Sylhet, Bangladesh, from July 2017 to June 2018. Sex determination of the collected unknown sacra was conducted using discriminant function analysis. It was found that 50% (30) were male and 50% (30%) were female. The unpaired t-tests and chi-square were utilized to determine the statistical significance.

Results: Out of 60 sacra, eight (13.33%) samples presented with sacralization. This study found that males had significantly higher straight (p=0.05) and curved (p=0.05) lengths of sacrococcygeal vertebrae. The sacrococcygeal curvature index (SCI) showed statistically significant (p=0.05) differences between the sexes.

Conclusion: Sacralization may exert an impact on the caudal block. It could extend the second stage of the labor process with perineal tears. Therefore, knowledge about the anatomical variation of the coccygeal vertebra is essential.

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.

A perspective on wrong level, wrong side, and wrong site spine surgery

Background:

Four of the most common “errors” in spine surgery include: operating on the wrong patient, doing the wrong procedure, performing wrong-level surgery (WLS), and/or performing wrong-sided surgery (WSS). Although preoperative verification protocols (i.e. Universal Protocol, routine Time-Outs, and using the 3 R’s (i.e. right patient, right procedure, right level/side)) have largely limited the first two “errors,” WLS and WSS still occur with an unacceptably high frequency.

Methods:

In 20 studies, we identified the predominant factors contributing to WLS/WSS; unusual/anatomical anomalies/variants (i.e. sacralized lumbar vertebrae. lumbarized sacral vertebra, Klippel-Feil vertebrae, block vertebrae, butterfly vertebrae, obesity/morbid obesity), inadequate/poor interpretation of X-rays/fluoroscopic intraoperative images, and failure to follow different verification protocols.

Results:

“Human error” was another major risk factor contributing to the failure to operate at the correct level/side (WLS/WSS). Factors comprising “human error” included; surgeon/staff fatigue, rushing, emergency circumstances, lack of communication, hierarchical behavior in the operating room, and failure to “speak up”.

Conclusion:

Utilizing the Universal Protocol, routine Time Outs, and the 3 R’s largelly avoid operating on the wrong spine patient, and performing the wrong procedure. However, these guidelines have not yet sufficiently reduced the frequently of WLS and WSS. Greater recognition of the potential pitfalls contributing to WLS/WSS as reviewed in this perspective should better equip spine surgeons to avert/limit such “errors” in the future.

Vertebral Formulae and Congenital Vertebral Anomalies in Guinea Pigs: A Retrospective Radiographic Study

Simple Summary

Guinea pigs are popular pets, but there is still a lack of information about their morphology. Variable morphology of the vertebral column can lead to incorrect localization of spinal diseases or the site of surgical intervention. This study aimed to determine the numerical variants of vertebral column and prevalence, localization, and type of congenital anomalies of the vertebral column. Vertebral column radiographs were reviewed in 240 guinea pigs, and nine numerical variants of the vertebral column were noticed. The most common vertebral formula, seven cervical, 13 thoracic, six lumbar, four sacral, and five to seven caudal vertebrae, was found in 75% of guinea pigs. Congenital anomalies were also found as incidental findings in 12.5% of guinea pigs, mostly in the thoracolumbar and lumbosacral regions. The most common congenital anomalies were a variable morphology of the last pair of ribs in the thoracolumbar region and transitional vertebra with a mixed morphological characteristic of lumbar and sacral vertebrae in the lumbosacral region. The cervical region was the least common region for congenital anomalies of the vertebral column. Our results contribute to the knowledge of clinical morphology in guinea pigs applicable in both, research and clinical practice.

Abstract

The objectives of this retrospective study of 240 guinea pigs (148 females and 92 males) were to determine the prevalence of different vertebral formulae and the type and anatomical localization of congenital vertebral anomalies (CVA). Radiographs of the cervical (C), thoracic (Th), lumbar (L), sacral (S), and caudal (Cd) part of the vertebral column were reviewed. Morphology and number of vertebrae in each segment of the vertebral column and type and localization of CVA were recorded. In 210/240 guinea pigs (87.50%) with normal vertebral morphology, nine vertebral formulae were found with constant number of C but variable number of Th, L, and S vertebrae: C7/Th13/L6/S4/Cd5-7 (75%), C7/Th13/L6/S3/Cd6-7 (4.17%), C7/Th13/L5/S4/Cd6-7 (2.50%), C7/Th13/L6/S5/Cd5-6 (1.67%), C7/Th12/L6/S4/Cd6 (1.25%), C7/Th13/L7/S4/Cd6 (1.25%), C7/Th13/L7/S3/Cd6-7 (0.83%), C7/Th12/L7/S4/Cd5 (0.42%), C7/Th13/L5/S5/Cd7 (0.42%). CVA were found in 30/240 (12.5%) of guinea pigs, mostly as a transitional vertebra (28/30), which represents 100% of single CVA localised in cervicothoracic (n = 1), thoracolumbar (n = 22) and lumbosacral segments (n = 5). Five morphological variants of thoracolumbar transitional vertebrae (TTV) were identified. Two (2/30) guinea pigs had a combination of CVA: cervical block vertebra and TTV (n = 1) and TTV and lumbosacral transitional vertebra (LTV) (n = 1). These findings suggest that guinea pigs’ vertebral column displays more morphological variants with occasional CVA predominantly transitional vertebrae.