The intent is to provide relief from pain and nerve damage. Several studies have shown that spine surgery is at the highest risk for litigation among the surgical subspecialties.12,29 The majority of claims are related to technical and procedural errors,29 including misplaced pedicle and/or lateral mass screws. Spine 16(8 Suppl):S455458, 1991. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Int Orthop 20:3542, 1996. 2013;123(9):20992103. 5 Those authors recommend that particular care should be taken in inserting the washers without cross threading and ensuring that they are locked down tightly, with an adequate length of rod protruding beyond the screw. The plaintiff received $2.4 million for pain and suffering and loss of enjoyment of life, $2 million for lost income and approximately $123,000 for medical expenses. Sethi MK, Obremskey WT, Natividad H, et al. Administrative/technical/material support: Mehta, Wang, KD Than. 16. Thoracic pedicle screw placement: Free-hand technique - Bioline A misplacement rate of more than 20 % (129 misplaced screws out of 608) seems to be unacceptable compared to only 4.5 % misplacements when using CT-navigation leading to the conclusion that pedicle screw instrumentation in the middle and upper thoracic area should be carried out with the help of navigation only. Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. Twenty-one patients (18.8%) had thoracolumbar injuries, and loss of immediate postoperative deformity correction ranged from 1.4 to 4.5. 2012;41(2):6973. 2011;306(10):1088. They both had motor deficits from which 1 patient recovered completely. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. It should be used by experienced and qualified surgeons who are familiar with the pitfalls associated with its use. Disc space narrowing was the most common problem after instrumented arthrodesis and was observed in 27 patients (24.1%). Neurosurgeons and orthopedic surgeons were named as the defendant in an equal number of cases, and the decision for the plaintiff versus the defendant was also similar between specialties. 5-7 Materials and Methods This is a retrospective study of kyphotic spondylitis tuberculosis (Stb) patients conducted at Fatmawati General Hospital, Jakarta, Indonesia, through the year 2020-2021. The initial search using the terms above returned 3654 cases. Materials and Methods Sixty . Results: JAMA. Although the rationale for using pedicle screw fixation is fairly clear, controversy continues regarding the application of pedicle instrumentation for spine arthrodesis, especially on the degenerative lumbar spine. It should be used by experienced and qualified surgeons who are aware of the pitfalls associated with its use. Some error has occurred while processing your request. 22. haroinfather roblox id McAfee PC, Weiland DJ, Carlow JJ: Survivorship analysis of pedicle spinal instrumentation. J Bone Joint Surg 73A:11791184, 1991. Pullout performance comparison of pedicle screws based on cement application and design parameters Tolga Tolunay, Cemile Bagl, Teyfik Demir, Mesut E Yaman, and Arslan K Arslan Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 2015 229: 11 , 786-793 Download Citation There were 74 men and 38 women, with a mean age of 47 years (range, 1872 years). 8,24,25,32. The screws were needed to stabilize the spine and fix the fused vertebrae in place. ObjectThe goal of this study was to determine the incidence of screw misplacement and complications in a group of 102 patients who underwent transpedicle screw fixation in the lumbosacral spine with conventional open technique and intraoperative. Stauffer RN, Coventry MB: Posterolateral lumbar-spine fusion: Analysis of the Mayo clinic series. Statistical analysis: Sankey. In situ spine arthrodesis permits load sharing by the vertebral bodies, preventing fatigue failure of the implant. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Bydon M, Xu R, Amin AG, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. In addition, studies have shown that over 85% of malpractice claims are either dismissed or settled out of court,14 which likely results in a high degree of underreporting. Harris RI, Wiley JJ: Acquired spondylolysis as a sequel to spine fusion. Malpractice litigation following spine surgery. However, this is the first study to evaluate the direct medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the US and presents important information that may support the routine use of intraoperative imaging confirmation (via 3D fluoroscopy or intraoperative CT) and/or navigated screw placement (either computer- or robot-assisted) as a potential method to decrease the risk of future litigation during spinal fusion procedures. NCI CPTC Antibody Characterization Program. may email you for journal alerts and information, but is committed Malpractice claims in spine surgery in Germany: a 5-year analysis. Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. Malpractice issues in neurological surgery. Spine 6:263267, 1981. Orthop Trans 11:99, 1987. 2021 Nov;9(6):1541-1548. doi: 10.1007/s43390-021-00377-5. All the incidental dural tears were repaired immediately and produced no clinical sequelae. Ann R Coll Surg Engl. In addition, seven (6.3%) dural tears occurred during the decompression and none occurred during instrumentation. Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England. Image intensification and the technique recommended by Weinstein et al 32 was used for screw placement in the lumbar vertebrae, whereas Chopin blocks (Medtronic Sofamor Danek) with two screws diverging bilaterally were used for sacral fixation. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults, Spinal fusion in the United States: analysis of trends from 1998 to 2008, Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws, The accuracy of pedicle screw placement using intraoperative image guidance systems, Accuracy of pedicle screw insertion by AIRO, intraoperative CT in complex spinal deformity assessed by a new classification based on technical complexity of screw insertion, Pedicle screw placement accuracy using ultra-low radiation imaging with image enhancement versus conventional fluoroscopy in minimally invasive transforaminal lumbar interbody fusion: an internally randomized controlled trial, Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients, Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO, Accuracy of pedicle screw placement and clinical outcomes of robot-assisted technique versus conventional freehand technique in spine surgery from nine randomized controlled trials: a meta-analysis, Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison, Verdict/Settlement Search and Inclusion/Exclusion Criteria, Plaintiff Claim and Index Surgery Information, Impact of Medical Malpractice on Neurosurgeon and Orthopedic Surgeon Careers, Financial Burden of Medical Malpractice Claims Related to Misplaced Pedicle and/or Lateral Mass Screws, Frequency of Misplaced Pedicle and Lateral Mass Screws in Spine Surgery, Strategies to Improve the Accuracy of Screw Placement in Spine Surgery, Top 25 Cited Gamma Knife Surgery Articles - Trigeminal Neuralgia, Top 25 Cited Gamma Knife Surgery Articles - Volume 111, https://doi.org/10.3171/2020.8.FOCUS20600, https://www.bls.gov/data/inflation_calculator.htm, Volume 49 (2020): Issue 5 (Nov 2020): Medicolegal issues in neurosurgery, Single vs multiple misplaced screw(s), no. Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. J Pediatr Orthop. Likewise, cases are uploaded on a voluntary basis by state and federal judges and courts, which may lead to selection bias. West III JL, Bradford DS, Ogilvie JW: Complications of the variable screw pedicle screw fixation. J Bone Joint Surg 45A:11591170, 1963. Careers. 20. Complications were classified as general, hardware-related, problems associated with the instrumented segments, junctional level problems, and problems related with balance (Table 2). A neurologic deficit developed in one patient (0.9%) who had partial bilateral drop feet after reduction of L4L5 spondylolisthesis. Operative information including fusion level, number of levels fused, level of misplaced screw(s), single versus multiple misplaced screw(s), presence of known CSF leakage, and primary injury due to screw misplacement was also collected. Your current browser may not support copying via this button. (A) Anteroposterior and (B) lateral radiographs taken 1 year after surgery show upper screw breakage in the application of a short Cotrel-Dubousset construct in a T12 burst fracture. Rothberg MB, Class J, Bishop TF, et al. We attribute the 24.1% disc space narrowing in the instrumented segments mainly to the severe injury of the disc and communication of the end plate in burst fractures, which could accelerate the disc degeneration and narrowing. With pedicle shapes and sizes varying wildly in the scoliotic spine, misplacement of a screwas well as and under- or oversizingare real possibilities in spine surgery. Clin Orthop 203:717, 1986. Harrington PR, Tullos HS: Reduction of severe spondylolisthesis in children. Waddell G, Kummell EG, Lotto WN, et al: Failed lumbar disc surgery and repeat surgery following industrial injuries. The case facts centered on a spinal surgery the 34 year-old plaintiff had undergone at Central DuPage Hospital. We avoid using sharp automated drilling, and probe fully the pedicle cavity to prevent nerve root impairment. J Neurosurg Spine. Rynecki ND, Coban D, Gantz O, et al. Rovit RL, Simon AS, Drew J, et al. Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants Irwin v. Alan Loren, M.D. True accuracy of percutaneous pedicle screw placement in thoracic and Svider PF, Kovalerchik O, Mauro AC, et al. 35. Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and, Malpractice liability and defensive medicine: a national survey of neurosurgeons, Defensive medicine among high-risk specialist physicians in a volatile malpractice environment, Defensive medicine: a culprit in spiking healthcare costs, Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study, Defensive medicine in U.S. spine neurosurgery, Personal consequences of malpractice lawsuits on American surgeons. Wolters Kluwer Health Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. As compared to cases in 19952009, those in 20102019 resulted in a significantly higher average nominal payout to plaintiffs ($776,439 $74,460 vs $1,506,000 $385,527, p = 0.028). Figure 1: Lower thoracic pedicles provide the firm purchase of the pedicle screw from a lateral starting point and 10-15 degrees convergent angle Surgical technique "Free Hand" pedicle screw placement [50] Our "Free Hand" technique is equivalent for lumbar and Despite these failures, solid spinal arthrodesis was obtained in all patients. Can Postoperative Radiographs Accurately Identify Screw Misplacements? Categorical and continuous data are described as frequency (percentage) and median (interquartile range), respectively, except for the use of mean standard deviation for award amounts since both nominal and inflation-adjusted award totals passed (alpha = 0.05) the DAgostino-Pearson omnibus normality test. This decision must be made on a case-by-case basis at the surgeons and patients discretion after a thorough discussion of the associated risks and benefits of revision surgery. Spine 18:983991, 1993. Through the use of expert witness testimony, Mr. da Costa was able to prove to the jury that by misplacing the pedicle screw during the surgery, and failing to timely diagnose and correct the malpositioned screw, Defendants deviated from accepted standards of care. Larson AN, Santos ER, Polly DW Jr, Ledonio CG, Sembrano JN, Mielke CH, Guidera KJ. Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. Spine 24:23522357, 1999. Intraoperative pedicle fractures requiring further points of fixation. Hardware problems were those related to the physical change of metal and screw position. J Spinal Disord Tech. Robotic-assisted pedicle screw placement fails to reduce overall Methods. A p < 0.05 was considered statistically significant. GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). Thus, meaningful efforts to limit the rate of misplaced pedicle and lateral mass screws, such as the routine use of intraoperative imaging confirmation and/or computer- or robot-assisted navigation, should be carefully considered. Objective: Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. There were nine instrumentation failures at the thoracolumbar area (seven patients), lumbar area (one patient), and lumbosacral area (one patient). Per-patient analysis reveals more concerning numbers toward screw misplacement. When grouped by US region, most cases occurred in the Northeast (n = 25, 36.8%), followed by the West (n = 15, 22.1%; Fig. Over 40% of patients had screws with either some/major concern. . 2. Potential complications may include increased pain, infection, or mechanical . This study has shown that percutaneous insertion of pedicle screws in the lumbar spine is a safe and reliable technique, and despite the low misplacement rate of only 6.6%, it should be kept in mind that the surgical procedure is technically demanding and should be performed only by experienced spine surgeons. Continued clinical experience with various pedicle screw implant systems has led to ongoing improvements in system design to minimize implant failure rates and to improve ease of system application. Pedicle screw placement is a common procedure.
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