Audit of a Standard Operating Procedure to Prevent Wrong-Level Lumbar Spinal
Surgery with Intra-Operative X-Ray
One of the most preventable errors that could occur during
spinal surgery is operating on the wrong site. Surgery done on the
wrong site includes either operating at an unplanned side or level.
In spinal surgery, the most common error for wrong site
surgery is a procedure done one level above the intended level.
Wrong-level spinal surgery is considered a ‘never event’ and is under-reported.
The rate of wrong level spine surgery ranges widely in the literature.
It is estimated that at least 50% of spine surgeons will perform at least one
wrong level procedure in their career.
A national survey done on incorrect site surgery among neurosurgeons
in Canada-based on anonymous questions self-assessment-concluded
that corrected wrong level lumbar discectomies
rate was estimated to be 12.8 per 10,000 operations,
which was much higher than cervical discectomies at 7.6 per 10,000 operations.
Careful pre-operative assessment along with robust pre- and intra-operative
localization techniques is crucial in improving the quality of the surgery.
Historically, the surgeons use palpation or “counting” from
a fixed reference point such as L5-S1 vertebrae for determining
the level of operation in lumbar spine surgery.
More recently, X-rays and fluoroscopy are increasingly and almost universally used.
However, use of X-rays once and only at the beginning of the procedure is not thought to
be enough and there are standard operating procedures occasionally suggested
to define the use of X-rays during these procedures, which are sometimes
modified by organizations for local use.
It remains the collective responsibility of the organization;
however, to ensure that such SOPs are strictly followed
to avoid errors during the surgery.
Neuro Open J. 2017; 4(1): 31-37. doi: 10.17140/NOJ-4-127
