pedicle screw misplacement malpractice

Sethi MK, Obremskey WT, Natividad H, et al. 33. In patients with degenerative conditions, all of the affected segments were included in the instrumentation and each vertebra was fixed with two pedicle screws. 18. Of the 112 patients, 57 patients had a lumbar degenerative disorder, (lumbar degenerative spinal canal stenosis in 23 patients, degenerative or spondylolytic spondylolisthesis in 12 patients, postlaminectomy instability or stenosis in 20 patients, and recurrent disc prolapse in two patients), 42 patients had spinal cord injury, eight patients had infection, and five patients had a spinal tumor (Table 1). 2014;96(4):266270. [] Computer-assisted computed tomography (CT) techniques have improved the overall accuracy for pedicle screw placement, and has reduced complication rates. Clin Orthop 203:7598, 1986. Nominal and inflation-adjusted award payouts were higher for trial verdicts than for settlement/arbitration, with a nominal average of $1,140,473 $841,683 versus $788,533 $306,186 awarded to the plaintiff, respectively (p = 0.30). Patient safety: disclosure of medical errors and risk mitigation, Neurosurgical practice liability: relative risk by procedure type. ABSTRACT: Pedicle screw loosening has been implicated in recurrent back pain after lumbar spinal fusion, but the degree of loosening has not been systematically quantied in patients. Disclaimer. Seabury SA, Chandra A, Lakdawalla DN, Jena AB. Spine 15:908912, 1990. government site. The contact form sends information by non-encrypted email, which is not secure. Dr. Goodwin has received grants from the Burroughs Wellcome Fund, North Carolina Spine Society, and Robert Wood Johnson Harold Amos Medical Faculty Development Program and the NIH/NINDS K12 NRCDP Physician Scientist Award. 2012;7(6):e39237. Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. 16. 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. 2002;27(22):24252430. The link was not copied. 2021 Nov;9(6):1541-1548. doi: 10.1007/s43390-021-00377-5. 2017 Mar;5(2):109-116. doi: 10.1016/j.jspd.2016.10.007. Elsamadicy AA, Sergesketter AR, Frakes MD, Lad SP. Seven hundred sixty-three screws were inserted in 138 patients. concluded that the robot-assisted technique was significantly more accurate than the traditional freehand technique.39 Despite the learning curve and initial cost of obtaining technologies such as 3D fluoroscopic devices, intraoperative CT, or robotic navigational systems, the routine use of these technologies for intraoperative imaging confirmation and potential revision of misplaced screws may help spine surgeons avoid inadvertent iatrogenic morbidity for their patients and potential litigation. Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. sharing sensitive information, make sure youre on a federal Nottmeier EW, Seemer W, Young PM. McLaughlin WM, Donnelley CA, Yu K, Gillinov SM, Tuason DA. Although the rate of the reported medical complications was high (36.5%), these did not significantly affect the final clinical outcome of the current patients. This occurred on only one side and the correction achieved by the instrumentation was maintained. (%), Pseudarthrosis requiring revision surgery. 2016;124(5):15241530. MeSH 13. Jena AB, Seabury S, Lakdawalla D, Chandra A. 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. In the current study, no incidence of bent and broken screws or tulip screw plug dislodgement necessitated additional treatment, and all the patients achieved solid fusion despite the failure of instrumentation. Unable to load your collection due to an error, Unable to load your delegates due to an error. The median time to case closure was longer for defendant-awarded cases, but this finding was not statistically significant (61.5 vs 56.3 months, p > 0.05). Median screw misplacement rate was 10% in group A and 13% in group B. Pedicle screws are used by spine surgeons as part of a fusion in which two adjacent bones in the spine are combined together as one. Methods: In their meta-analysis of nine randomized controlled trials, Li et al. Pitfall: Unstable injuries. Pediatric pedicle screw placement using intraoperative computed tomography and 3-dimensional image-guided navigation. All these problems were observed only just above the upper instrumentation level and all were observed in patients older than 55 years. Better strategies need to be devised for evaluation of screw placement, including establishment of a national database of deformity surgery, use of intra-operative image guidance, and reevaluation of postoperative low-dose CT imaging. Subjects were 10,754 patients (73,777 pedicle screws) who underwent PSF at 11 hospitals over 15 years. Likewise, cases are uploaded on a voluntary basis by state and federal judges and courts, which may lead to selection bias. Hardware-related failures were observed in 12 patients (10.7%). Accuracy of C2 pedicle screw placement using the anatomic freehand technique. Review of neurosurgery medical professional liability claims in the United States. 3. Guzek RH, Mitchell SL, Krakow AR, Harshavardhana NS, Sarkissian EJ, Flynn JM. Orthopedics. Nevertheless, research has shown that screws are misplaced in approximately 14%55% of cases using the standard techniques (freehand and 2D fluoroscopic guidance) employed by most spine surgeons,21,33 resulting in injury in approximately 1%8% of cases.21 In addition to the avoidable procedural risk to the patient, each misplaced screw carries the threat of future litigation, as reported above. Spine 24:23522357, 1999. Over 40% of patients had screws with either some/major concern. Plaintiff's expert was prepared to testify at trial that these complaints are characteristic of a malpositioned screw impinging upon a neural structure. In the current study, only five patients with junction problems above the instrumented area were observed with the following probable predisposing factors: an already degenerative disc, coronal imbalance, very long arthrodesis, and old age. Conversely, Nyquists foot drop did not resolve after the screw was removed, which begged the question of whether the foot drop was in fact caused by the misplaced screw. Segal J. The rate of misplaced pedicle screws ranges from 1.1% to 28.8%, 10 although neurologic injury from misdirected pedicle screws has been reported to occur in 0% to 12% of patients. Li HM, Zhang RJ, Shen CL. 1. Problems in the instrumented segments were considered those occurring from narrowing of the disc space greater than 3 mm, pseudarthrosis, and loss of reduction. We avoid using sharp automated drilling, and probe fully the pedicle cavity to prevent nerve root impairment. Spine 18:11601172, 1993. Orthop Trans 11:99, 1987. Nyquist had requested the defendants offer, which in retrospect was perhaps a poor decision in light of the Kane County jurys verdict. The radiology results showed that the surgical screw placed at the right L4-5 area had breached the medial wall and was actually extending into the spinal canal. Bydon M, Xu R, Amin AG, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Cookie Policy. Studdert DM, Mello MM, Sage WM, et al. PURPOSE This study aimed to compare rates of perioperative complications between robotic-assisted and conventional . 0 attorneys agreed. Defensive medicine in neurosurgery: the Canadian experience. Privacy Policy. Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. Likewise, research shows that breaches still occur when these tools are used,33,40 and some studies did not find a difference in pedicle breach rates compared to those with traditional fluoroscopic and freehand techniques.33 Ultimately, misplaced instrumentation is a risk of any spinal fusion surgery, and a thorough discussion of these risks, as well as the alternative management options, is essential to maintain high-quality patient care and to avoid litigation. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. Spine 13:10121018, 1988. This patient recovered completely in 6 weeks. There were two complete degenerations of the upper disc, one central canal stenosis, and two asymptomatic disc space narrowings and retrolistheses. Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). Clin Orthop 284:8090, 1992. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? Mohar J, Vali M, Podovovnik E, Mihali R. Eur Spine J. However, we did not observe any screw breakage in patients with a degenerative lumbar spine, and the absence of broken screws in this series is because arthrodesis in almost all patients occurred in situ. A total of 47 (69.1%) cases resulted in a decision for the defendant and 21 (30.9%) for the plaintiff. A neurologic deficit developed in one patient (0.9%) who had partial bilateral drop feet after reduction of L4L5 spondylolisthesis. A large number of studies have reported that in conventional thoracolumbar surgery, compared with traditional freehand screw placement, the accuracy of intraoperative pedicle screw placement has been improved with O-arm intraoperative navigation technology. 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. J Neurosurg Spine. Ann R Coll Surg Engl. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Neurologic injury. Except for the patient with an infected pseudarthrosis who had a flat back syndrome (sagittal imbalance) develop, coronal imbalance was observed in five patients (4.5%), and ranged from 7.5 to 12 (Fig 3). Unfortunately, the plaintiffs attorney was unable to offer an alternative theory of surgical negligence that would refute the defendants explanation. Clipboard, Search History, and several other advanced features are temporarily unavailable. Wolters Kluwer Health Most of these complications were minor and with the exception of two misplaced screws, did not contribute to the occurrence of neurologic impairment or severe pain. Eur Spine J. EOS System Courtesy of EOS imaging. Clinical Orthopaedics and Related Research411:86-94, June 2003. Saillant G: Etude anatomique des pedicules vertebraux: Application chirurgicale. Smith TR, Hulou MM, Yan SC, et al. Spine 18:23252326, 1993. In six of these patients with injuries at the thoracolumbar area (four patients with bent screws and two patients with broken screws), the loss of correction ranged from 3 to 4.5 without change of anatomic reduction (Fig 1). (A) Anteroposterior and (B) lateral radiographs taken 2 years after surgery show unilateral pseudarthrosis in a 55-year-old man with spinal stenosis. 15. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. J Neurosurg Spine. Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) 15. And while the offending screw was removed the next day, Nyquist continued to experience right foot drop, along with lower back pain and sciatica, i.e. 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. Bethesda, MD 20894, Web Policies Sub-analysis of adolescent idiopathic scoliotic patients showed no curve or patient characteristic that correlated with IMP or SAR. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim. 4. A p < 0.05 was considered statistically significant. The plaintiff will recover $2.25 million because of a high-low agreement the lawyers entered after closing arguments, the New Jersey Law Journal reports. 2020;162(6):13791387. GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). 2006;65(4):416421. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. What can spine surgeons do to improve patient care and avoid medical negligence suits? Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study. A.J. Results: A total of 2724 screws were placed in 127 patients. Spine (Phila Pa 1976). Clin Orthop 115:130139, 1976. 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. Using chi square analysis, statistically significant correlation was seen between disc space narrowing and loss of postoperative correction (p < 0.01). Acta Neurochir (Wien). Taylor CL. While reported to be one of the best legal research resources available and utilized in several previous studies,7,14,16,23,24 available court documents and clinical/operative details are highly variable and greatly limited among case files. Autor de la entrada Por ; Fecha de la entrada austin brown musician; matrix toners for bleached hair . In White AH, Rothman RH, Ray CD (eds). 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. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the . Instead, the defense offered up an alternative explanation for Nyquists foot drop. General complications were considered those developing during and after surgery that were not directly related to instrumentation. INCLUDE WHEN CITING DOI: 10.3171/2020.8.FOCUS20600. The literature gave a range of screw misplacement rates detected on postoperative imaging of between 1% and 18%, with the rate generally considered to be around 10%. In the current series, including general complications, only 48 patients (43%) had no notable complication and the remaining 64 patients (57%) had one or more complications. The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion.

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