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Wrong-Level Spine Surgery: Introduction of a Protocol for Avoidance of This Complication

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Complications in Neurosurgery

Part of the book series: Acta Neurochirurgica Supplement ((NEUROCHIRURGICA,volume 130))

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Abstract

Wrong-level spine surgery, in which an operation is performed at a vertebral level different from the intended one, is a rare but serious complication with wide-ranging medical and legal effects. Although many protocols have been developed to prevent such a serious unfavorable event, the problem has not yet been eliminated. Research into the effectiveness of strategies to prevent wrong-level spine surgery is lacking. Herein, we describe a case of 44-year-old woman presented with neck pain and bilateral upper extremity weakness and numbness. Magnetic resonance imaging showed C5/6 and C6/7 disc herniations with spinal cord compression. The patient underwent anterior cervical discectomy and fusion; however, at the conclusion of the surgery, intraoperative radiographs showed that it was accomplished at C4/5 and C5/6—one level above the intended level. On the basis of this case and similar ones, a new protocol was developed that included implementation of a Spine Level Safety Checklist to document the reference point, the landmark, and the level of exposure that is marked on the intraoperative radiograph. Since implementation of this protocol, the incidence of wrong-level spine surgery at the senior author’s institution has decreased from 4/7000 to 0/11,200. Adoption of this protocol by other centers is thus recommended to reduce the incidence of such complication.

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Conflict of Interest Statement

The authors have no conflict of interest concerning the reported materials or methods.

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Authors and Affiliations

  1. Harvard Medical School, Boston, MA, USA

    James Paul Agolia

  2. DeGroote School of Medicine, McMaster University, Faculty of Health Sciences, Hamilton General Hospital, Hamilton, ON, Canada

    Ekkehard M. Kasper

Authors
  1. James Paul Agolia
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  2. Ekkehard M. Kasper
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Corresponding author

Correspondence to Ekkehard M. Kasper .

Editor information

Editors and Affiliations

  1. Department of Neurosurgery, Bombay Hospital and Institute of Medical Sciences, Mumbai, India

    Keki E. Turel

  2. Department of Neurosurgery, Tokyo Women’s Medical University, Adachi Medical Center, Tokyo, Japan

    Mikhail F. Chernov

  3. Department of Neurosurgery, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India

    Hrishikesh Sarkar

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Agolia, J.P., Kasper, E.M. (2023). Wrong-Level Spine Surgery: Introduction of a Protocol for Avoidance of This Complication. In: Turel, K.E., Chernov, M.F., Sarkar, H. (eds) Complications in Neurosurgery. Acta Neurochirurgica Supplement, vol 130. Springer, Cham. https://doi.org/10.1007/978-3-030-12887-6_21

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  • DOI: https://doi.org/10.1007/978-3-030-12887-6_21

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-12886-9

  • Online ISBN: 978-3-030-12887-6

  • eBook Packages: MedicineMedicine (R0)

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