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Archive June 2020 XXI, No. 6

How to Prevent Wrong-Site Spine Surgery

Imaging enhancements and culture changes will ensure these errors truly are never events

Sheeraz Qureshi

Sheeraz Qureshi, MD, MBA


Hospital for Special Surgery
GOOD COUNT Sheeraz Qureshi, MD, MBA (left), counts the discs from the sacrum or the C2 vertebrae to avoid a wrong-site surgery.

The nature of spine surgery makes the risk of wrong-site errors greater than in any other surgical discipline. Similar-looking vertebrae, patient obesity, anatomic abnormalities and visualization limitations all play a role in surgeons mistaking which area of the spine they intended to work on. Thankfully, there are several solutions available — some expensive, some virtually free of cost — that can help surgeons properly identify the level of the spine that needs to be repaired or replaced.

1. Count correctly

Most vertebrae anatomy looks the same, so the only way to know you're at the correct spot is to find an anatomical landmark that looks different from the rest of the spine, and count vertebrae until you reach the disc that needs treatment. When surgeons operate in the lumbar region, for example, they generally find the sacrum and count up to the spinal level they want to work on. When dealing with the cervical spine, they count down from the C2 vertebrae. The thoracic spine can be most problematic because surgeons are not able to see the sacrum or the C2 vertebrae at the same time. Most operating rooms are limited because C-arms don't provide full-body fluoroscopic images, so surgeons must place an artificial marker to identify a place to start their count to the correct vertebrae.

Most spine surgeons make three localized counts to confirm the intended surgical site. One takes place pre-incision. After the patient is intubated, anesthetized and positioned for surgery, the first intraoperative image is taken with a C-arm. My general practice is to place a needle through the skin for the pre-incision imaging. The needle overlays the area of the spine I want to operate on. It shows up on the X-ray so I can confirm that it's at the vertebrae that needs repair.

The second X-ray is taken after the incision is made. The bone is exposed, but before the actual procedure has begun. I place a surgical tool on the bone and capture another image to make sure the bone I'm about to remove is the correct one. The count I make ends when I get to the disc that has the tool atop it. A third and final X-ray is taken after the procedure has been completed to confirm the location was correct.

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