A survey-based study of wrong-level lumbar spine surgery: the scope of the problem and current practices in place to help avoid these errors.

Journal Article (Journal Article)

OBJECTIVE: To understand better the scope of wrong-level lumbar spine surgery and current practices in place to help avoid such errors. METHODS: The Joint Section on Disorders of the Spine and Peripheral Nerves (Spine Section) developed a survey on single-level lumbar spine decompression surgery. Invitations to complete the Web-based survey were sent to all Spine Section members. Respondents were assured of confidentiality. RESULTS: There were 569 responses from 1045 requests (54%). Most surgeons either routinely (74%) or sometimes (11%) obtain preoperative imaging for incision planning. Most surgeons indicated that they obtained imaging after the incision was performed for localization either routinely before bone removal (73%) or most frequently before bone removal but occasionally after (16%). Almost 50% of reporting surgeons have performed wrong-level lumbar spine surgery at least once, and >10% have performed wrong-side lumbar spine surgery at least once. Nearly 20% of responding surgeons have been the subject of at least one malpractice case relating to these errors. Only 40% of respondents believed that the site marking/"time out" protocol of The Joint Commission on the Accreditation of Healthcare Organizations has led to a reduction in these errors. CONCLUSIONS: There is substantial heterogeneity in approaches used to localize operative levels in the lumbar spine. Existing safety protocols may not be mitigating wrong-level surgery to the extent previously thought.

Full Text

Duke Authors

Cited Authors

  • Groff, MW; Heller, JE; Potts, EA; Mummaneni, PV; Shaffrey, CI; Smith, JS

Published Date

  • 2013

Published In

Volume / Issue

  • 79 / 3-4

Start / End Page

  • 585 - 592

PubMed ID

  • 22480979

Electronic International Standard Serial Number (EISSN)

  • 1878-8769

Digital Object Identifier (DOI)

  • 10.1016/j.wneu.2012.03.017


  • eng

Conference Location

  • United States