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A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to
Michael W Groff1, Joshua E Heller, Eric A Potts
1Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
Objective:
To understand better the scope of wrong-level lumbar spine surgery and current practices in place to help avoid such errors.
Methods:
The Joint Section on Disorders of the Spine and Peripheral Nerves (Spine Section) developed a survey on single-level lumbar spine decompression surgery. Invitations to complete the Web-based survey were sent to all Spine Section members. Respondents were assured of confidentiality.
Results:
There were 569 responses from 1045 requests (54%). Most surgeons either routinely (74%) or sometimes (11%) obtain preoperative imaging for incision planning. Most surgeons indicated that they obtained imaging after the incision was performed for localization either routinely before bone removal (73%) or most frequently before bone removal but occasionally after (16%). Almost 50% of reporting surgeons have performed wrong-level lumbar spine surgery at least once, and >10% have performed wrong-side lumbar spine surgery at least once. Nearly 20% of responding surgeons have been the subject of at least one malpractice case relating to these errors. Only 40% of respondents believed that the site marking/"time out" protocol of The Joint Commission on the Accreditation of Healthcare Organizations has led to a reduction in these errors.
Conclusions:
There is substantial heterogeneity in approaches used to localize operative levels in the lumbar spine. Existing safety protocols may not be mitigating wrong-level surgery to the extent previously thought.
