Accuracy and evaluation of irradiation of novel localization devices with unique three-dimensional structures in microendoscopic spine surgery.

BACKGROUND: Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure. PURPOSE: To evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery. STUDY DESIGN: This was a retrospective cohort study. METHODS: In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope. RESULTS: Eight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10-1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1-7 s). CONCLUSIONS: Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.

Evaluating compliance with the best practice guidelines for wrong-level surgery prevention in high-risk pediatric spine surgery.

PURPOSE: In 2018, Best Practice Guidelines (BPGs) were published for preventing wrong-level surgery in pediatric spinal deformity, but successful implementation has not been established. The purpose of this study was to evaluate BPG compliance 5 years after publication. We hypothesized higher compliance among BPG authors and among surgeons with more experience, higher caseload, and awareness of the BPGs. METHODS: We queried North American and European surgeons, authors and nonauthors, and members of pediatric spinal study groups on adherence to BPGs using an anonymous survey consisting of 18 Likert scale questions. Respondents provided years in practice, yearly caseload, and guideline awareness. Mean compliance scores (MCS) were developed by correlating Likert responses with MCS scores ("None of the time" = no compliance = MCS 0, "Sometimes" = weak to moderate = MCS 1, "Most of the time" = high = MCS 2, and "All the time" = perfect = MCS 3). RESULTS: Of the 134 respondents, 81.5% reported high or perfect compliance. Average MCS for all guidelines was 2.4 ± 0.4. North American and European surgeons showed no compliance differences (2.4 vs. 2.3, p = 0.07). Authors and nonauthors showed significantly different compliance scores (2.8 vs 2.4, p < 0.001), as did surgeons with and without knowledge of the BPGs (2.5 vs 2.2, p < 0.001). BPG awareness and compliance showed a moderate positive correlation (r = 0.48, p < 0.001), with non-significant associations between compliance and both years in practice (r = 0.41, p = 0.64) and yearly caseload (r = 0.02, p = 0.87). CONCLUSION: Surgeons reported high or perfect compliance 81.5% of the time with BPGs for preventing wrong-level surgery. Authorship and BPG awareness showed increased compliance. Location, study group membership, years in practice, and yearly caseload did not affect compliance. LEVEL OF EVIDENCE: Level V-expert opinion.

If you look this way, you will see it: cranial shift in adolescent idiopathic scoliosis.

INTRODUCTION: Anatomical variations in the spine can be seen in each transitional border, either toward the skull as 'cranial shifts' or away as caudal shifts. Cranial shifting (CS) occurs when there is presence of occipitalization, C7 cervical costae or prominent transverse processes, thoracolumbar transitional vertebrae (TLTV) at T12 level, L5 sacralization, and sacrococcygeal fusion. We termed the coexistence of sacralization of L5 and absence or remarkable reduction of T12 rib size in AIS as Abul cranial shift (ACS). In this descriptive clinical study, primary aim was to investigate the incidence of ACS in AIS. METHODS: Retrospective analysis of 187 surgically treated AIS cases was performed. Demographic data were recorded. The incidence of the specific set of anatomic variations including lumbosacral transitional vertebrae, TLTV, transverse process changes in C7 vertebrae, and posterior lumbosacral neural arch cleft formations (NACf) were evaluated in the radiological images. RESULTS: 36 (19%) of 187 cases had ACS. ACS was detected in only 1 of 19 male cases (5%), while in 35 of 168 female cases (21%). Forty-one cases had sacralization of L5 (22%). There were only eleven pair of ribs in 14 (7%) of 187 cases and 10 (28%) of 36 ACS cases. Forty cases had NACf (21%). ACS and NACf coexistence were observed in 8 (22%) of 36 ACS cases. CONCLUSION: Accurate spinal column assessment is critical in adolescent idiopathic scoliosis (AIS). ACS may be observed in up to one in five AIS cases and its presence should not be neglected to avoid wrong level surgery.

"Spine Surgery Checklist": A Step towards Perfection through Protocols.

STUDY DESIGN: A retrospective study. PURPOSE: This study aimed to evaluate the effectiveness of a novel checklist that was designed specifically for the "spine-surgerysubspecialty" to reduce the incidence of some common preventable human errors and major perioperative complications in spine surgery. OVERVIEW OF LITERATURE: We propose a unique spine surgery-specific checklist that recognizes the risk factors, anticipates the possible human errors, and thus helps in preventing these errors. This checklist is associated with increased patient safety awareness, improved communication (keeps everyone updated regarding their responsibilities), reduction in the surgical claims, and reduction in the number of postoperative complications, including mortality. METHODS: This retrospective pilot study was performed at single center on 858 spine surgery patients. The patients were divided into the following two groups: the study group (after implementation of the checklist [2016-2017]) and the control group (before the implementation of the checklist [2015-2016]). The incidence of common preventable human errors and major perioperative complications in spine surgeries were recorded and compared between the two groups. RESULTS: The prevalence of wrong-level surgeries was 0%, and the overall prevalence of the preventable errors was 1.63% (7/428). The rate of adverse, near-miss, and no-harm events was 0.23% (1/428), 0.70% (3/428) and 0.70% (3/428), respectively. The preoperative, intraoperative, and postoperative errors were 0.70% (3/428), 0.23% (1/428), and 0.70 (3/428), respectively. The reoperation rate related to preventable errors reduced after the checklist was used. There were significant differences in the total preventable errors related to complications, such as infections, prolonged hospital stays, and unplanned hospital readmission/revision surgeries (p=0.001). CONCLUSIONS: The authors propose the first-of-its kind spine surgery-specific checklist that is comprehensive and involves perioperative parameters. The checklist is easy to use, safe, and effective for reducing the unforgiving errors and perioperative complications. However, its broader implementation would require validation in large, multi-center, randomized control studies.

Pre- and intraoperative thoracic spine localization techniques: a systematic review.

OBJECTIVE: In the era of modern medicine with an armamentarium full of state-of-the art technologies at our disposal, the incidence of wrong-level spinal surgery remains problematic. In particular, the thoracic spine presents a challenge for accurate localization due partly to body habitus, anatomical variations, and radiographic artifact from the ribs and scapula. The present review aims to assess and describe thoracic spine localization techniques. METHODS: The authors performed a literature search using the PubMed database from 1990 to 2020, compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 27 articles were included in this qualitative review. RESULTS: A number of pre- and intraoperative strategies have been devised and employed to facilitate correct-level localization. Some of the more well-described approaches include fiducial metallic markers (screw or gold), metallic coils, polymethylmethacrylate, methylene blue, marking wire, use of intraoperative neuronavigation, intraoperative localization techniques (including using a needle, temperature probe, fluoroscopy, MRI, and ultrasonography), and skin marking. CONCLUSIONS: While a number of techniques exist to accurately localize lesions in the thoracic spine, each has its advantages and disadvantages. Ultimately, the localization technique deployed by the spine surgeon will be patient-specific but often based on surgeon preference.

Spinal navigation applied to the anterior approach for the resection of thoracic disc herniation: patient series.

BACKGROUND: Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches. OBSERVATIONS: Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness. LESSONS: In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.

A reproducible and reliable localization technique for lumbar spine surgery that minimizes unintended-level exposure and wrong-level surgery.

BACKGROUND CONTEXT: Exposure of unintended levels (defined as a spinal segment outside the intended surgical levels) is unnecessary and potentially adds to operative time and patient morbidity. Wrong-level surgery (defined as decompression, instrumentation, or fusion of a spinal segment not part of the intended surgical procedure) clearly adds to morbidity as well as putting the surgeon at medicolegal risk. PURPOSE: To describe a localization technique for posterior lumbar spine surgery to minimize both unintended-level exposure and wrong-level surgery. STUDY DESIGN: Consecutive case series. PATIENT SAMPLE: One thousand nine hundred and eighty-six consecutive posterior lumbar operations performed from January 2010 to January 2017 using this technique were reviewed. OUTCOME MEASURES: The primary outcome measure was the incidence of unintended-level exposure and wrong-level surgery. METHODS: This localization technique was consistently used for determination of skin incision, soft tissue dissection, and identification of spinal levels for all patients undergoing posterior lumbar surgery during the time interval noted. Two spinal needles are inserted under sterile technique 3cm lateral to the midline before incision at the approximate cranial and caudal aspects of the anticipated incision based on external landmarks. A cross-table lateral X-ray before incision is obtained and the actual incision is adjusted based on the location of the spinal needles. Once dissection is carried down to the facet capsules, spinal needles are then placed in adjacent facets, and a second cross-table lateral film is obtained to confirm appropriate levels. A retrospective review of all posterior lumbar cases was performed to determine the incidence of unintended-level exposure and wrong-level surgery using this technique. RESULTS: There were no wrong-level surgeries during this time period. There were six (0.30%) cases of unintended-level exposure. CONCLUSIONS: The technique described provides surgeons with a reliable, accurate, and easily reproducible method for localizing surgical levels during posterior lumbar spine surgery while minimizing exposure of uninvolved areas. This technique offers distinct advantages over previously proposed protocols and may lead to a widely accepted system for intraoperative spinal level identification.

Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity.

STUDY DESIGN: Consensus-building using the Delphi and nominal group technique. OBJECTIVE: To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. METHODS: The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. RESULTS: Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. CONCLUSION: We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. LEVEL OF EVIDENCE: Level V.

Marking wire placement for improved accuracy in thoracic spinal surgery.

OBJECTIVE: To present an innovative approach that does not rely on intraoperative X-ray imaging for identifying thoracic target levels and critically appraise its value in reducing the risk of wrong-level surgery and radiation exposure. METHODS: 96 patients admitted for surgery of the thoracic spine were prospectively enrolled, undergoing a total of 99 marking wire placements. Preoperatively a flexible marking wire derived from breast cancer surgery was inserted with computed tomography (CT) guidance at the site of interest--the wire was then used as an intraoperative guidance tool. RESULTS: Wire placement was considered successful in 96 cases (97%). Most common pathologies were tumors (62.5%) and degenerative disorders (16.7%). Effective doses from CT imaging were significantly higher for wire placements in the upper third of the thoracic spine compared to the lower two thirds (p = 0.015). Radiation exposure to operating room personnel could be reduced by more than 90% in all non-instrumented cases. No adverse reactions were observed, one patient (1.04%) underwent surgical revision due to an epifascial empyema. No wires had to be removed due to lack of patient compliance or infection. CONCLUSIONS: This is a safe and practical approach to identify the level of interest in thoracic spinal surgery employing a marking wire. Its application merits consideration in any spinal case where X-ray localization could prove unsafe, particularly in cases lacking bony pathologies such as intradural tumors.

Analysis of the techniques for thoracic- and lumbar-level localization during posterior spine surgery and the occurrence of wrong-level surgery: results from a national survey.

BACKGROUND CONTEXT: Despite the frequency with which surgeons perform posterior spinal surgery and the precautions against wrong-site surgery, operations on incorrect levels still occur. Wrong-level exposure is documented in 0.32% to 15% of cases. Additionally, there is little consensus as to what is the most accurate method for localizing the correct spinal level. PURPOSE: The purpose of this study is to investigate the most commonly used localization methods and their association with wrong-level surgery, to determine the prevalence of wrong-level localization, and to identify circumstances commonly associated with wrong-level surgery, and to offer recommendations that may reduce the incidence of these errors. STUDY DESIGN/SETTING: This was an online survey study that was distributed to North American Spine Society (NASS) members (including both orthopedic surgeons and neurosurgeons). The survey was sent as a Web link within an e-mail. PATIENT SAMPLE: A total of 2,338 surgeons received the survey, 532 opened the survey, and 173 completed it (7.4% response rate). The survey was only sent once, as recommended by NASS. Of those that responded, 72% (124 of 173) were orthopedic surgeons, 28% (49 of 173) were neurosurgeons, and 73% (126 of 173) were spine fellowship trained. OUTCOME MEASURES: We sought to investigate self-reported localization methods that are most commonly used (both anatomic landmarks and imaging techniques), the prevalence of wrong-level surgery, and any correlations between localization method and wrong-level surgery. METHODS: An eight-question anonymous survey was distributed to members of NASS, including orthopedic surgeons and neurosurgeons. There was no pilot testing or validation performed for this survey. The survey was sent as a Web link within an e-mail. Some questions asked surgeons to select as many responses as applicable, and others allowed surgeons to describe in detail any cases of wrong-level surgery. This study neither requires nor receives funding; additionally, no conflicts of interests were reported. RESULTS: Fluoroscopy was the most commonly used imaging technique for thoracic and lumbar surgeries (89% and 86%, respectively), followed by plain radiographs (54% and 58%, respectively). Surgeons were allowed to select as many responses as applicable, and 76 surgeons reported using both plain radiographs and fluoroscopy. The facet joint with corresponding pedicle was the most commonly used anatomic landmark for localization of thoracic and lumbar surgeries (67% and 59%, respectively), followed by the spinous process (49% and 52%, respectively). Sixty-eight percent of surgeons admitted to wrong-level localization, some of which were rectified intraoperatively, during their careers. Fifty-six percent of these surgeons reported using plain radiographs and 44% used fluoroscopy when the errors occurred. Common sources of preoperative errors included failure to visualize known reference points, recognize unconventional spinal anatomy, and adequately visualize the level because of large body habitus. Common sources of intraoperative errors included poor communication, failure to relocalize after exposure, and poor counting methods. CONCLUSIONS: Despite the variety of localization modalities, most surgeons use only a few. Whereas wrong-level localization is relatively rare, the ideal frequency is never. There is no standard approach that will entirely eliminate these mistakes; however, using a localization time out and increasing awareness of common sources of error may help decrease the incidence of wrong-level spine surgery.

The incidence of bifid c7 spinous processes.

For posterior cervical surgery, if the operation only involves the lower cervical area, counting from C2 is impractical and the level may not be visible on X-rays. In such cases, we usually place a marker at the top of the incision and also rely on the size and monofid shape of the C7 spinous process. Relying on the C7 morphology, however, we initially instrumented the wrong levels in a case where the patient had a bifid C7 spinous process. We therefore sought to determine the frequency of bifid cervicothoracic spinous processes. Computed tomography axial images of C6, C7, and T1 from 516 patients were evaluated. The spinous processes were classified into three categories: "bifid," "partially bifid," and "monofid." C6 spinous process was monofid in 47.9% of cases, partially bifid in 4.2% of cases, and bifid in 47.9% of cases. C7 spinous process was monofid in 99.2% of cases, partially bifid in 0.5% of cases, and bifid in 0.3% of cases. T1 was monofid in all cases. A truly bifid C7 spinous process occurs 0.3% of the time and therefore is not a reliable landmark for choosing fusion levels. This knowledge hopefully helps prevent the type of wrong-level instrumentation that we performed.

Wrong-level surgery: A unique problem in spine surgery.

BACKGROUND: Even though a lot of effort has gone into preventing operating at the wrong site and wrong patient, wrong-level surgery is a unique problem in spine surgery. METHODS: The current method to prevent wrong level spine surgery performed is mainly relied on intra-operative X-ray. Unfortunately, because of the unique features and anatomy of the spinal column, wrong level spine surgery still happens. There are situations that even with intraoperative X-ray, correct level still cannot be reliably identified. RESULTS: Examples of patient whose surgery can easily be performed on the wrong level are illustrated. A protocol to prevent wrong-level spine surgery preformed is developed. CONCLUSION: The consequence of wrong-level spine surgery not only generates another surgery of the intended level; it is usually also associated with lawsuit. Strictly following this protocol can prevent wrong-level spine surgery.