One of the common means of doing so is to place a screw into each of two adjacent spinal bones (vertebrae), and then a rod between them. Clin Orthop 203:126134, 1986. Agarwal N, Gupta R, Agarwal P, et al. 5. When grouped by US region, most cases occurred in the Northeast (n = 25, 36.8%), followed by the West (n = 15, 22.1%; Fig. In order to prove medical malpractice occurred, the plaintiffs attorney needs to show not only the plaintiff experienced a poor medical outcome, but that it was directly caused by medical negligence. J Pediatr Orthop. 2006;65(4):416421. 20 Tips to Avoid and Handle Problems in the Placement - ScienceDirect Elsamadicy AA, Sergesketter AR, Frakes MD, Lad SP. And while the jury debated for about two hours, at the end of its deliberation it sided with the defendants and entered a not guilty verdict. MeSH J Neurosurg Spine. Critically revising the article: all authors. Patient-specific 3D-printed surgical guides for pedicle screw insertion Reviewed submitted version of manuscript: all authors. McLaughlin WM, Donnelley CA, Yu K, Gillinov SM, Tuason DA. In patients with degenerative conditions, all of the affected segments were included in the instrumentation and each vertebra was fixed with two pedicle screws. Luque ER: Segmental spinal instrumentation of lumbar spine. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Intraoperative and postoperative complications were recorded by the authors and the results were evaluated by an independent observer. The incidence of screw failure, which can occur despite solid arthrodesis, 7 in the current series was 8% and mainly involved patients with thoracolumbar injury. The last two patients had a T12L1 fracture-dislocation and a L4L5 spondylolytic spondylolisthesis at the site of plug dislodgments. Three slender patients complained of soft tissue irritation and a bothersome prominence because of the screws bulky profile. Review of neurosurgery medical professional liability claims in the United States. Pedicle screw fixation is an effective but demanding method to treat various spinal disorders and is associated with a significant complication rate. 20. Steffee AD, Biscup RS, Sitkowski DJ: Segmental spine plates with pedicle screw fixation: A new internal fixation device for disorders of the lumbar and thoracolumbar spine. A total of 2396 screws were placed accurately (87.96%). Descriptive analysis of state and federal spine surgery malpractice litigation in the United States. Spine arthrodesis was evaluated with plain AP and lateral radiographs taken 1 year after surgery. Pedicle screw accuracy in thoracolumbar fractures- is routine Screw misplacement. doi: 10.1097/BPO.0000000000001828. Spine 15:908912, 1990. Health Aff (Millwood). This site needs JavaScript to work properly. Study design: 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. Yuan HA, Garfin SR, Dickman CA, Mardjetko SM: A historical cohort study of pedicle screw fixation in thoracic, lumbar and sacral spinal fusions. In six patients (5.3%) with degenerative spine disease, the disc material had been removed. This device was used with an early version of the Cotrel-Dubousset instrumentation to provide sacral fixation and it is rarely used since the more widespread use of newer spine fixation systems. Dr. Friedlander did not order a CT or MRI until January 2013, when the pedicle screw was found to be in the wrong location and a failed fusion was diagnosed, according to the suit. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). In 2 patients, misplacement of pedicle screws was recognized intraoperatively and all implants were removed. Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. Thankfully, most screws are just misplaced by a millimeter or two out the front or are slightly off medially, so they are not doing real damage. I won't be at the office but I will check my voice mail. Procedural errors led to combined payouts totaling $124,943,933 in neurosurgery claims between 2003 and 2012 in a study looking at data from the Physician Insurers Association of America Data Sharing Project.10 However, our study is the first to report the direct medicolegal impact of screw misplacement on US spine surgery, with 30.9% of judgments/settlements in favor of the plaintiff, resulting in average payouts of $1,204,422 $753,832 per claim. Nahed BV, Babu MA, Smith TR, Heary RF. It has a great developing technique that is used for fixation and fusion in spine surgery. Background The objective of this cadaveric study was to analyze the effects of iatrogenic pedicle perforations from screw misplacement on the mean pullout strength of lower thoracic and lumbar pedicle screws. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. Moffatt-Bruce SD, Ferdinand FD, Fann JI. Pedicle Screw Malposition Expert Witness: Malposition Can Lead to What can spine surgeons do to improve patient care and avoid medical negligence suits? 16. Hecht N, Kamphuis M, Czabanka M, et al. The screws were needed to stabilize the spine and fix the fused vertebrae in place. 27,30 Infected pseudarthrosis developed in one patient (0.9%) with an L4S1 arthrodesis, and the instrumentation was removed 18 months later resulting in a flat back syndrome. The states with the most cases included California (n = 10, 14.7%), New York (n = 6, 8.8%), Pennsylvania (n = 6, 8.8%), and Illinois (n = 5, 7.3%; Table 2). 2014;21(3):320328. Furthermore, 25 patients (22.3%) reported persistent pain in the iliac crest (donor graft site) for several months, for which they were treated with repeated lidocaine injections and analgesics. (A) Anteroposterior and (B) lateral radiographs taken 2 years after surgery show unilateral pseudarthrosis in a 55-year-old man with spinal stenosis. Li HM, Zhang RJ, Shen CL. All the operations were done by one surgeon (PK). The largest inflation-adjusted payout awarded to the plaintiff ($3,372,185) for nerve root injury occurred in a 36-year-old male who had undergone an L4S1 posterior spinal fusion, which resulted in permanent and direct injury to right L5 and S1 nerve roots, with foot drop and radiculopathy. Guzek RH, Mitchell SL, Krakow AR, Harshavardhana NS, Sarkissian EJ, Flynn JM. Patient safety: disclosure of medical errors and risk mitigation, Neurosurgical practice liability: relative risk by procedure type. Methods. When adjusted for inflation, these values increased to $1,330,201 $882,023 versus $970,832 $381,619, respectively (p = 0.32; Fig. The total number of reoperations for MPS and patient clinical data were obtained from medical records at each hospital. 38. 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. 2012;37(1):6776. Many technological advances have been made over the past several decades in an effort to improve the accuracy of screw placement in spine surgery.3436 For example, 3D fluoroscopybased image guidance has been shown to decrease the pedicle breach rate in several studies compared to the rate with 2D fluoroscopic guidance or the freehand technique, particularly in deformity and revision surgeries.21,34,36,37 CT guidance or intraoperative confirmation has also been shown to further improve the accuracy of pedicle screw placement,3638 with reported accuracy rates of 89%100% reported in the literature, depending on the authors breach criteria.35 However, it is important to note that the use of this technology is often accompanied by a lower threshold for intraoperative screw revision, sometimes leading to higher rates of replaced screws.33 Arguably, these improved trajectories may avoid iatrogenic neurological deficits due to prolonged nerve root compression or even improve the stability of the construct;34,37 however, prospective studies of long-term outcomes and rates of revision surgery remain sparse in the literature. However, this difference was no longer significant when adjusted for inflation ($1,016,000 $90,875 vs $1,630,000 $422,405, p = 0.09). Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. Are We Underestimating the Significance of Pedicle Screw Misplacement 18. Steinmann JC, Herkowitz HN: Pseudarthrosis of the spine. Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison. Forty-seven intraoperative and medical complications were observed in 41 patients (36.6%). All Rights Reserved. Call Us Now For a Free Consultation | Toll Free: 800.583.8002 | Local: 312.346.0045, Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants , Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation , Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in, $75 Million Jury Verdict in Failure to Timely Diagnose Stroke, $18 Million Jury Verdict in Late Diagnosis of Breast Cancer, $300,000 Settlement for Excessive Use of Radiation, Chicago Medical Malpractice Lawyer Kreisman Law Offices Home, Contact Illinois Personal Injury Attorney Kreisman Law Offices. 2009;10(1):3339. Int Orthop 20:3542, 1996. Acta Neurochir (Wien). 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). 7. 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%. Reprint requests to Pavlos Katonis, MD, 99 Minoos & Thenon Street, 71305, Heraklion, Crete, Greece. Malpractice liability and defensive medicine: a national survey of neurosurgeons. Copyright 2023 Becker's Healthcare. 2018;41(5):e615e620. Rather, the defense demonstrated that although the misplaced screw had in fact irritated the L4 nerve root for the six days before it was removed, the related symptoms resolved with the screws removal. However, the highest offer had been a combined $300,000 from the two defendants. The site is secure. 15. Hardware-related failures were observed in 12 patients (10.7%). 2016;124(5):15241530. Clinical Orthopaedics and Related Research411:86-94, June 2003. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. Retrospective analysis of reasons and revision strategy for failed thoracolumbar fracture surgery by posterior approach: a series of 31 cases. Notwithstanding these concessions, the MDU argued that misplacement of pedicle screw tracts was common in surgery of this kind, even in experienced and competent hands. 3,4,9,29,34 In addition, developments in surgical technique and implant design have decreased operative risk and implant-related complications.