Moral complexity

Area of Science:

• Orthopaedic Surgery
• Spine Surgery
• Surgical Errors

Background:

• Multilevel spinal decompression and instrumentation (L3-S1) was planned.
• The procedure was delayed, starting late in the afternoon.
• The attending surgeon opted against obtaining localization radiographs before proceeding.

Purpose of the Study:

• To report a case of incorrect spinal instrumentation placement.
• To highlight the importance of intraoperative imaging in spine surgery.
• To discuss the management of intraoperative surgical errors.

Main Methods:

• A four-level pedicle screw instrumentation and posterior-lateral fusion was performed.
• Intraoperative radiographs were suggested but declined by the attending surgeon.
• Post-instrumentation radiographs revealed incorrect level placement (L2-L5 instead of L3-S1).

Main Results:

• Decompression was accurate at the intended levels.
• Spinal instrumentation and fusion spanned L2 to L5, deviating from the planned L3 to S1.
• The attending surgeon overruled the Fellow's recommendation to correct the instrumentation before wound closure.

Conclusions:

• Failure to obtain intraoperative radiographs can lead to significant surgical errors in spinal instrumentation.
• Adherence to established surgical protocols, including imaging, is crucial for patient safety.
• Effective communication and decision-making in managing intraoperative deviations are vital in complex spine surgeries.