Audit of a Standard Operating Procedure to Prevent Wrong-Level Lumbar Spinal Surgery with Intra-Operative X-Ray

Abstract

Introduction: One of the major errors that can be encountered by a spinal surgeon is operating at
the wrong level/side. However, wrong-level spinal surgery is considered a ‘never-event’ and is
under-reported. Many surgeons have traditionally adopted the technique of palpating or “counting”
from L5-S1 to determine the operative level in lumbar spine procedures without necessarily
the use of intraoperative X-ray control. Most surgeons these days; however, use X-rays or
fluoroscopy during the surgery. There is no universal standard operating procedure (SOP) for
the use of X-rays or fluoroscopy during spinal surgery and the compliance of the surgeons for
any local SOP is unknown.
Aim: The audit primarily intended to check the compliance with an established local SOP using
X-ray to identify lumbar spinal level. We also determined the accuracy of lumbar spine
level marking by palpation. We also tried to quantify the intra-operative error rate following
pre-operative X-ray level marking. Overall, the optimum role of X-rays was determined for
adequate level of lumber decompression.
Methods: The audit was performed as a prospective clinical audit within a single neurosurgical
department. Data collected from theatre logbook, medical notes and picture archive and communication
system (PACS). An established local SOP for use of X-rays during spinal surgery
was used as a benchmark to audit local practice.
Cycle 1: Every lumbar discectomy and decompression from June to November 2015 (6 months)
was obtained. The findings were presented in our local clinical effectiveness meeting with the
aim check local practice and suggest improvements.
Cycle 2: Re-audit a further 6 months, December 2015 to May 2016, to see the significance of
the change implemented.
Results: In the first cycle, one patient did not receive pre-operative X-ray. While all other
patients received pre-operative X-rays, the number of exposures was available in only 71% of
patients, out of which 39% required one exposure, 43% required two exposures, 16% required
three exposures and 2% required four exposures. Twenty eight cases (13.9%) were recorded to
have intra-operative X-ray level checked due to doubt, out of which 22 cases were found to be
on an incorrect level.
In the second cycle, all patients received pre-operative X-rays and the number of exposures was
recorded for all, out of which 52% required one exposure, 32% required two exposures, 13%
required three exposures and 3% required four exposures. Twenty cases (9.7%) were recorded
to have intra-operative X-ray level checked due to an arising doubt, out of which only 7 were
found to be on an incorrect level.