Kristopher T. Kimmell, MD, with the CSNS Ad Hoc Committee for Patient Safety
Editor’s Note: The Council of State Neurosurgical Societies (CSNS) Ad Hoc Neurosurgical Committee for Patient Safety consists of the following individuals, whose contributions were vital to this article: Chair Gregory H. Smith, DO; Wayel Kaakaji, MD; Sherry Taylor, MD; John McGregor, MD; Krystal Tomei, MD; Brad Zacharia, MD; Jack Dunn, MD; Charles Rosen, MD, PHD, FAANS; Jason Hauptman, MD, PhD.
Disclaimer: The content expressed in this article reflects the authors’ views and not necessarily those of the American Association of Neurological Surgeons.
Introduction
Your stomach churns as you review the words in your brain, just to make sure you got them correctly:
- ”It’s the wrong level.”
- “But I counted down from the ribs, I checked based on your read from the pre-op films.”
- “I didn’t count down from the ribs on the pre-op films, I counted up from the sacrum ….”
You hang up the phone, rescrub and gown, and proceed carefully through the remainder of the case to ensure there are no other complications, and to give yourself time to prepare for the conversation in the recovery room with the patient and his family.
Wrong-level spine surgery. The very sound of the words may make some surgeons hearts’ skip a beat. Even in the era of pre- and intra-operative imaging, wrong level or site spinal surgery is an all too common event. Recent surveys by North American Spine Society (NASS) (9) andAmerican Academy of Neurological Surgery (10) suggest that nearly half of neurosurgeons will be involved in a wrong-site spine surgery during their career.
