Zdeblick TA: A prospective randomized study of lumbar fusion: Preliminary results. 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. 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. J Bone Joint Surg 61A:201207, 1979. A TLIF is a surgical procedure that attempts to fuse vertebrae in order to stabilize the patient's spine. 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 J Neurosurg Spine. Phone/Fax: 30-2810-318361; E-mail: [emailprotected]. J Bone Joint Surg 54A:11951204, 1972. With increasing pedicle screw usage, the number of patients with misplaced screws will likely increase proportionally. 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). Sethi MK, Obremskey WT, Natividad H, et al. Spine 8:970981, 1996. Judgment information associated with a defendant (surgeon) versus plaintiff (patient) ruling, trial versus settlement versus arbitration decision, award amount, and time to decision or case closure from index surgery was also recorded. 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. 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. Edwards CC: Spinal screw fixation of the lumbar and sacral spine: Early results treating the first 50 cases. 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. Eur Spine J. You may be trying to access this site from a secured browser on the server. Malpractice issues in neurological surgery. 2018;41(5):e615e620. While the majority of verdicts are found in favor of the defendant (surgeon), over 30% of cases in this study were found in favor of the plaintiff (patient), resulting in average inflation-adjusted payouts of over $1.2 million per claim over the past 25 years. The screws were needed to stabilize the spine and fix the fused vertebrae in place. Plaintiff award amounts were adjusted for inflation as of April 2020 using an online inflation calculator provided by the US Bureau of Labor Statistics (https://www.bls.gov/data/inflation_calculator.htm). In four of these patients, bent screws occurred at 8 to 10 months after surgery; in three patients, broken screw necks were seen 1 year after surgery and in two patients, tulip screw plug dislodgments were observed at 4 and 6 months postoperatively, respectively. Lali Sekhon, Jocelyn Idema & more: 4 spine and neurosurgeons making headlines, Spinal cord stimulation trumps medication for pain reduction 7 takeaways, Dr. Khalid Kurtom on major trends in spinal cord injury surgery. Am J Orthop. Unilateral nonunion was seen in three patients (2.7%), associated with implant failure in one of the patients. 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. J Neurosurg Spine. Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study. Clin Orthop 203:4553, 1986. 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). They both had motor deficits from which 1 patient recovered completely. 2014;21(3):320328. In situ spine arthrodesis permits load sharing by the vertebral bodies, preventing fatigue failure of the implant. 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). 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. Epstein NE. Defensive medicine in neurosurgery: the Canadian experience. Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. 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. Rovit RL, Simon AS, Drew J, et al. Level of evidence: A total of 247 screws (9.07%) were BMP, 52 (1.91%) were IMP, and 29 (1.06%) were considered SAR. 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. 2020;45(2):E111E119. Epub 2022 Oct 29. 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. Whitecloud III TS, Butler JC, Cohen JL, Candelora PD: Complications with the variable spinal plating system. 37. 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. 2012;37(1):6776. A.J. 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). All these problems were observed only just above the upper instrumentation level and all were observed in patients older than 55 years. Your current browser may not support copying via this button. 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. Disclosures Dr. Karikari is a consultant for NuVasive, Globus, Johnson & Johnson, and DePuy and receives a spine fellowship fund from NuVasive. 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. Spine 6:263267, 1981. Spine 18:983991, 1993. Intraoperative pedicle fractures requiring further points of fixation. 2021 Jul 1;41(Suppl 1):S80-S86. It is easier to confuse a jury than convince a judge: the crisis in medical malpractice. The rate of medical complications was 8%. Ahmadi SA, Sadat H, Scheufler KM, et al. 2021 Nov;9(6):1541-1548. doi: 10.1007/s43390-021-00377-5. Lumbar Spine Surgery. Complete degeneration of the upper disc developed in two patients who had spinal stenosis and degenerative scoliosis. Dr. Shaffrey has received grants from the NIH and Department of Defense. PLoS One. This step in implant evolution was inevitable, because prior phases of implant development did not control each plane of motion segment stress. Makhni MC, Park PJ, Jimenez J, et al. (A) Anteroposterior and (B) lateral radiographs taken 2 years after surgery show unilateral pseudarthrosis in a 55-year-old man with spinal stenosis. Patient safety: disclosure of medical errors and risk mitigation. Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary? The median time to case closure was 56.3 (35.267.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.477.2) months for defendant (surgeon) verdicts (p = 0.117). L3S1 spine arthrodesis was done in the first patient but the correction of scoliosis was not sufficient and coronal imbalance persisted after surgery, which accelerated the degeneration of the level just above the arthrodesis. Moreover, several cases stated that the surgeon used only the anteroposterior or the lateral view, but not both, and the plaintiffs counsel used this information in support of their claim. Retrospective analysis of reasons and revision strategy for failed thoracolumbar fracture surgery by posterior approach: a series of 31 cases. Seven hundred sixty-three screws were inserted in 138 patients. Legal liability in iatrogenic orbital injury. 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. * I won't be at the office but I will check my voice mail. 2018;29(4):397406. The rod is held in place by "pedicle screws," which the surgeon must insert into the pedicles. Epstein NE. Spine 24:23522357, 1999. Spine 15:908912, 1990. 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. 2017;27(4):470475. However, published reports are increasingly demonstrative of the positive effect of pedicle fixation on arthrodesis and successful outcome in the treatment of patients with these disorders. Pedicle screw placement safety with the aid of patient-specific guides in a case series of patients with thoracic scoliosis. Excessive hemorrhage occurred in two patients (1.8%) with coagulation disorders. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. Spine 13:696706, 1988. and 17.1% of the patients included had at least one screw misplaced. Despite these failures, solid spinal arthrodesis was obtained in all patients. Subjects were 10,754 patients (73,777 pedicle screws) who underwent PSF at 11 hospitals over 15 years. 8600 Rockville Pike 1). It has a great developing technique that is used for fixation and fusion in spine surgery. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. Copyright 2023 Becker's Healthcare. Guzek RH, Mitchell SL, Krakow AR, Harshavardhana NS, Sarkissian EJ, Flynn JM. Sarwahi V, Ayan S, Amaral T, Wendolowski S, Gecelter R, Lo Y, Thornhill B. Spine Deform. None of these complications resulted in additional surgery or in a significant increase of morbidity. 2013;34(6):699705. Fager CA. There were 74 men and 38 women, with a mean age of 47 years (range, 1872 years). Laryngoscope. Ann R Coll Surg Engl. Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. Before Harrington and Tullos 11 first reported the technique of transpedicle screw fixation, and Roy-Camille et al 23 popularized the first practical method of pedicle screw fixation. Statistical analysis: Sankey. Spine (Phila Pa 1976). States were then grouped by US region and case year by 5-year intervals. 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%). Unfortunately, the plaintiffs attorney was unable to offer an alternative theory of surgical negligence that would refute the defendants explanation. Facebook Google Plus Youtube RSS Email. Ultimately, additional prospective, multiinstitutional large-volume studies are needed to validate these findings, and future studies should evaluate the long-term impact on the routine use of intraoperative imaging confirmation and/or computer- or robot-assisted navigation on the frequency and success of malpractice claims related to misplaced pedicle and lateral mass screws. The majority of screws were misplaced in the lumbar spine for both plaintiff- and defendant-awarded cases (66.7% vs 57.4%, respectively, p = 0.564; Table 1). 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%. Din RS, Yan SC, Cote DJ, et al. Orthopedics. [] Computer-assisted computed tomography (CT) techniques have improved the overall accuracy for pedicle screw placement, and has reduced complication rates. Over 40% of patients had screws with either some/major concern. All the operations were done by one surgeon (PK). 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. 22. A retrospective review of charts, XRs and low-dose CT scans of 127 patients who underwent spinal fusion with pedicle screws for spinal deformity was performed. 2. Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. Lehmann TR, LaRocca HS: Repeat lumbar surgery: A review of patients with failure from previous lumbar surgery treated with spinal canal exploration and lumbar spine fusion. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. Spine 17:834837, 1992. There were two complete degenerations of the upper disc, one central canal stenosis, and two asymptomatic disc space narrowings and retrolistheses. 2022 Dec;31(12):3544-3550. doi: 10.1007/s00586-022-07427-0. 29. Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. Analysis and interpretation of data: Sankey, TT Than. Autor de la entrada Por ; Fecha de la entrada austin brown musician; matrix toners for bleached hair . Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo. Rynecki ND, Coban D, Gantz O, et al. Clinical Orthopaedics and Related Research411:86-94, June 2003. An official website of the United States government. 6. A total of 2396 screws were placed accurately (87.96%). may email you for journal alerts and information, but is committed Using chi square analysis, statistically significant correlation was seen between disc space narrowing and loss of postoperative correction (p < 0.01). Bydon M, Xu R, Amin AG, et al. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. Elizabeth Hofheinz, M.P.H., M.Ed. What can spine surgeons do to improve patient care and avoid medical negligence suits? doi: 10.1097/BPO.0000000000001828. Per-patient analysis showed 23 (18.11%) of patients had all screws AP. It argued that the foot drop was unavoidable and due to the surgeons need to manipulate the right L5 nerve root in order to remove Nyquists herniated disc during the spinal fusion surgery. 8 spine surgeon insights, Lumbar spinal fusion cost in the 10 largest US cities, 2 MLB players undergo offseason spine surgeries, Salem Regional Medical Center adds spine surgeon, Here's how 6 spine surgeons prepare before a busy day, Total disc replacement cost in the 10 largest US cities, Study finds surgery more effective than conventional treatment for spinal stenosis, Dr. Rick Price completes his 50th AR spine case, Orthopedic surgeon among 2 convicted in $31M Medicare fraud scheme, SSM Health sues 2 resigning orthopedic surgeons, Surgeon leaves Rothman after 12 years to establish boutique spine practice, Jury awards $9.2M in botched spine surgery case, 'The numbers don't lie': Endoscopy to become more prominent among next generation of spine surgeons, Patient sues estate of late spine surgeon, 10 surgeons on the most controversial trends in spine, Connecticut orthopedic surgeon fined, reprimanded for operating on wrong hip, Ohio neurosurgeon facing wrongful death suit, Orthopedic surgeons at SSM Health resign, plan to start independent group, Wealthiest US orthopedic surgeon has a net worth of $1.8B, Orthopedic surgeons leaving SSM Health will partner with HOPCo for independent group, Wisconsin orthopedic surgeon sanctioned in patient's death, Healthgrades' best hospitals for spine surgery: 2023, How spine surgery competition is evolving by market: New York, Arizona, California and more, Indianapolis Colts linebacker has back surgery after consultation with Dr. Robert Watkins, Former Philadelphia Eagles player wins $43.5M verdict in knee injury case, California hospital cleared in counterfeit spine implant case, Georgia orthopedic clinic settles kickback suit, 22 hospitals ranked top 25 orthopedic hospitals 3+ years in a row, Stryker vs. Johnson & Johnson vs. Zimmer Biomet: How they compare in Q3, Neurosurgeon sentenced 5 years for accepting $3.3M in bribes, 12 surgeons who are leaving orthopedic groups for private practices, SSM Health canceling procedures as 11 orthopedic surgeons begin early departure, Aetna revises lumbar disc replacement policy, Indiana orthopedic surgeon settles Medicaid fraud allegations for $700K, 2 orthopedic hospitals facing Medicare readmission penalties, University of Toledo Medical Center suspends orthopedic chair, Here's what HOPCo's 1st Wisconsin partnership will look like, 2 Florida orthopedic providers merge to form 17-physician practice, 'This system is unsustainable': Why orthopedic surgeons do not feel fairly compensated, Orthopedic surgeon convicted for $31M staged fall scheme, Orthopedic surgeon buys $2M Chicago church, plans to convert to community hub, New Hampshire orthopedic surgeon arrested for alleged patient abuse, 8th Annual Becker's Health IT + Digital Health + RCM Annual Meeting. Whitecloud et al 35 reported an overall 45% rate of minor and major complications, with the rate of complications increasing to 63% in patients who had previous lumbar surgery. A CT scan was taken to try and identify the underlying neurological problem that might be causing the new symptom. Thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. 2022 Jun;8(2):234-241. doi: 10.21037/jss-22-28. A p < 0.05 was considered statistically significant. 1 Although this technique has advantages over open instrumentation, it also presents new challenges and specific complications.

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