What’s New in the Patient Safety World

December 2011

Novel Technique to Prevent Wrong Level Spine Surgery



Despite focused attention on prevention of wrong-site surgery over the past 15 years, we continue to see cases of wrong-site surgery. While methods for site marking have been adopted widely, marking sites related to spine levels has remained particularly problematic. That’s because of things like anatomical variation in the number of rib-bearing vertebrae, obesity, osteoporosis, etc.


Recently, a novel technique was applied to site marking for thoracic spine surgery (Upadhyaya 2011). The authors inserted “fiducial” screws, under conscious sedation and with CT guidance, into the spine preoperatively in an ambulatory setting. Plain x-rays or reconstructed CT scan views could then be utilized intraoperatively to reference the spinal level at which the fiducial screw had been placed. The screw placement took about an hour and involved an amount of radiation roughly equivalent to a chest x-ray.


The authors then studied 26 cases of thoracic spine surgery and compared these to 26 historical controls. No wrong-level procedures occurred in either group. They found that the amount of intraoperative fluoroscopy required in cases with the fiducial screws was on average 12 minutes shorter than that in the control cases, thus exposing the patient (and operating room staff) to less radiation. The procedure was roughly cost neutral, since the extra cost of the screw was offset by the shorter OR time.


We previously mentioned an update on wrong-site surgery in the VA medical system (Neily 2011) that showed a reduction in adverse events in and out of the OR after implementation of a number of patient safety interventions, including their Medical Team Training (MTT) program. But the service with the highest rate of wrong-site adverse events was Neurosurgery, largely because of problems localizing the correct spine level in spine surgery. We suspect that spine surgery remains most problematic in most centers, largely for the reasons noted above. It will be interesting to see if the above method of spine level localization is successful in reducing wrong-level spine surgery. However, given the overall low incidence of wrong-site surgery, it is very difficult to be able to attribute improvement to any one specific intervention and it would be impractical to do a randomized control trial because of the huge population that would be required.




Some of our prior columns related to wrong-site surgery:


Patient Safety Tip of the Week columns:

  September 23, 2008 “Checklists and Wrong Site Surgery

  June 5, 2007 “ Patient Safety in Ambulatoy Surgery

  March 11, 2008 “Lessons from Ophthalmology

  September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned

  November 25, 2008 “Wrong-Site Neurosurgery

  January 19, 2010 “Timeouts and Safe Surgery

  June 8, 2010 “Surgical Safety Checklist for Cataract Surgery

  December 6, 2010 “More Tips to Prevent Wrong-Site Surgery

  June 6, 2011 “Timeouts Outside the OR


What’s New in the Patient Safety World columns:

  July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery

  August 2011 “New Wrong-Site Surgery Resources









Upadhyaya CD, Wu J-C, Chin CT, et al. Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement: Clinical article. Journal of Neurosurgery: Spine 2011; Posted online on 4 Nov 2011.




Neily J, Mills PD, Eldridge N, et al. Incorrect Surgical Procedures Within and Outside of the Operating Room. A Follow-up Report.

Arch Surg. 2011; 146(11): 1235-1239














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