In an effort to reduce the risk of wrong level spinal surgery, the COA believes the following recommendations may be useful.

Brendan D. Lewis, M.D., FRCSC
Clinical Assistant Professor of Surgery
Chief Dept of Orthopaedics W.M.R.H.
Cornerbrook, NF

In the Winter 1993 issue of its Information Letter, the Canadian Medical Protective Association (CMPA) reported that a significant number of settlements have to be made on behalf of orthopaedic surgeons because of wrong patient or wrong side procedures, and wrong spinal level operations.

Recent correspondence with the CMPA has indicated that the incidence of these problems is low.

Attempts to avoid the wrong patient or wrong side require strict attention to detail and careful pre-surgery inspection. The COA under the guidance of Dr. Paul H. Wright has generated a position paper on wrong sided surgery.

Initials on the painful leg, especially for disc surgery, ensures one is on the correct side. If needed this could be easily checked intraoperatively by lifting the drapes.		Marker on spinous process at beginning of surgery to confirm level. This may not always be clear. An itrradiscal marker can be used if there was difficulty with this marker.
This holder, easily fabricated, allows the x-ray film held appropriately positioned without risk to anyone for radiation exposure.		Correct imaging studies appropriately displayed during surgery.

New technology, especially the CAT scan, is accurate and readily demonstrates uncontestable evidence of surgical level.

In an effort to reduce the risk of wrong level spinal surgery, the Canadian Orthopaedic Association believes the following recommendations may be useful:

1. Preoperative discussion with the patient is important to confirm symptoms.
   
   
2. For disc surgery or spinal decompression for leg pain, signing the affected leg with your initials will ensure the correct side is operated on. Intraoperative confirmation can easily be done if needed.
   
   
3. Appropriate preoperative radiographic films and imaging studies should be reviewed personally by the surgeon and correlated with the patient’s symptoms and the findings on physical examination. Reading the reports of such investigation is not enough; the films themselves should be viewed before the surgery to confirm the level and the side.
   
   
4. The possibility of spinal anomalies should be considered in every case in order that they may be identified preoperatively. A transitional L5 Vertebrae or arthritic lipping of L5-S1 facets may affect the identification of the first mobile level from the sacrum. Rocking the spinous process with a Kocher or Towel Clip may not provide the anticipated movement and then wrongly indicate that level as S1-S2.
   
   
5. Awareness of a spina bifida will reduce the risk of dural injury on exposure.
   
   
6. The relevant radiographic films should be displayed on the operating room view boxes throughout the procedure. Before starting the procedure the surgeon should ensure that the films are correctly placed on the view boxes and confirm once again that what they show correlates with the symptoms and physical findings.
   
   
7. In cervical spine surgery, an intraoperative radiograph with the appropriately placed marker will help to identify the correct level. Before the marker is removed, one should ensure that an indelible mark remains upon the appropriate bone or disc.
   
   
8. When obtaining a cross-table lateral in the operating room, it is important the x-ray “beam” is truly transverse and the plate at a right angle to the beam.
   
   
9. In lumbar spine surgery:
   

(a) An intraoperative radiograph with the appropriate marker should be done when there is any confusion as to the level, or when the expected or appropriate pathology is not found.

(b) The pathology found should correspond to the preoperative symptoms and physical findings, and to the preoperative radiographs and imaging studies.

(c) At the lumbosacral junction, identifying the sacrum and counting the motion segments up from the sacrum, taking into account any spinal anomaly, is useful. More accurate, however, is a cross table lateral with a marker (e.g.) K-wire in the disc, towel clip in the spinous process. Before the marker is removed, one should ensure there is an indelible mark upon the appropriate bone or disc.

(d) Dissection laterally at the lumbosacral junction to locate the transverse process adjacent to the sacrum may be helpful.