Published 3/1/2013
Jennie McKee

Wrong-Site Spine Surgery: An Underreported Problem?

Investigators urge more emphasis on best practices to prevent surgical errors

“Wrong-site surgery is the sentinel event most frequently reported to The Joint Commission,” said Bradford Currier, MD, professor of orthopaedics at the Mayo Clinic in Rochester, Minn., during a presentation at the 2012 Cervical Spine Research Society annual meeting.

“Approximately 30 percent of wrong-site surgeries reported in Minnesota are wrong-level spine procedures,” he continued. “Despite its frequency and substantial health and medicolegal ramifications, wrong-site spine surgery (WSSS) is poorly defined, and consequently has ambiguous and variable reporting requirements.”

Dr. Currier and his colleagues conducted a study to better identify what constitutes WSSS, as well as to determine the self-reported incidence of WSSS among practicing spine surgeons, with the ultimate goal of encouraging the use of best practices to improve patient safety.

Surveying spine surgeons
To conduct the study, the investigators provided a 4-page questionnaire to the following three groups of practicing spine surgeons:

  • Participants at a Spine Study Group (SSG) meeting
  • Faculty members of AO Spine North America (AOSNA)
  • Members of the Society for Minimally Invasive Spine Surgery (SMISS)

A total of 181 surgeons (51 SSG attendees and faculty members, 74 AOSNA faculty members, and 56 SMISS faculty members) completed the questionnaire. The SSG attendees completed the survey in person, while the AOSNA faculty members and SMISS members completed it via email. The survey contained questions about the following:

  • Surgeon’s background, such as years in practice, number of surgeries performed per year, and areas of specialty
  • History of having performed or having been accused of performing WSSS

Prevalence and severity
Nearly half (43.9 percent) of survey respondents reported having performed WSSS, while only 14.4 percent of respondents reported having been accused of performing WSSS.

“The only significant association between surgeon characteristics and having performed WSSS was that those who were in practice longer were more likely to report having committed an error and to have been accused of WSSS,” noted Dr. Currier. The odds ratio associated with increased duration of practice and an increased likelihood of having performed WSSS was 1.5 per 5 years of practice (P < 0.001); the odds ratio was 1.4 per 5 years of practice (P = 0.007) for having been accused of performing WSSS.

Vignettes measure perceptions
According to Dr. Currier, the survey also presented 12 clinical vignettes describing a variety of situations (See “Is This Wrong-Site Spine Surgery?” sidebar.) Survey participants responded to each vignette indicating whether they believed it constituted a WSSS and, if so, how severe they believed the error was (scale of 0 to 10, from least to most severe).

Researchers found a link between increased duration of practice and fewer vignettes being identified as WSSS (P = 0.019); they also found that respondents who had been in practice longer provided a slightly lower mean severity score ( P = 0.014) for vignette items.

“The standard deviations (SD) of the mean severity scores were relatively small, with only one vignette having an SD greater than 2.7,” he noted. “Ranking the vignettes by percentage of surgeons declaring errors to be WSSS and by mean severity score yielded nearly identical orders.”

Thus, said Dr. Currier, “the responses from the three different subgroups of respondents were remarkably consistent. The only significant associations were that surgeons with a personal history of WSSS and those in practice longer were slightly more lenient in their perception of the errors.”

Drawing conclusions
“In summary, WSSS constitutes a spectrum of errors, many of which do not reach the threshold of potential harm typical of other sentinel events,” said Dr. Currier. “These are common events, and they often go unreported.”

Based on the results of this study, personal experience and years in practice introduce a degree of bias in defining WSSS.

“Our goal in presenting this information is to encourage surgeons to share best practices to prevent WSSS and to provide guidance to hospital administrators and government officials regarding these events, with the overall aim of promoting a culture of safety,” he concluded.

Dr. Currier’s coauthors of “Wrong-Site Spine Surgery” are Daniel D. Bohl, MPH; Dirk R. Larson, MS; Hongbo Liu, MD; Ahmad Nassr, MD; and William E. Krauss, MD.

Disclosures: Dr. Currier—DePuy, A Johnson & Johnson Company; Stryker; Zimmer; Spinology Tenex; AO Spine North America. Dr. Nassr—Synthes. Mr. Bohl and Dr. Krauss—no information available. Mr. Larson and Dr. Liu—no conflicts.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

  • Wrong-site surgery, which includes wrong-level spine surgery, is the sentinel event most commonly reported to The Joint Commission.
  • Despite its frequency and significant ramifications, WSSS is poorly defined and has ambiguous and variable reporting requirements.
  • Investigators found that 43.9 percent of practicing orthopaedic spine surgeons who participated in the study reported having performed WSSS, and 14.4 percent of respondents reported having been accused of performing WSSS.
  • Responses regarding whether clinical vignettes constituted WSSS—and the severity of those errors—were mostly consistent among survey respondents.
  • Researchers found that those who had been in practice longer identified fewer vignettes as representing WSSS; these respondents also identified a slightly lower mean severity score (P = 0.014) for vignette items.

Is This Wrong-Site Spine Surgery?

The following vignettes were part of the survery:

A: You planned to perform an L4-L5 decompressive laminectomy. You removed ligamentum flavum at L3-L4 before you realized that you were not at L4-L5. You then performed an L4-L5 decompressive hemilaminotomy as planned. L3-L4 appears to be stable.

B: You planned to perform an L4-L5 decompressive hemilaminectomy. You did a hemilaminectomy and partial facetectomy at L3-L4 before you realized that the level was L3-L4. You then performed an L4-L5 decompressive hemilaminectomy as planned. L3-L4 appeared to be unstable and required a fusion during the index operation.