A neurologic deficit developed in one patient (0.9%) who had partial bilateral drop feet after reduction of L4L5 spondylolisthesis. Epub 2014 Apr 4. Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis. [] Computer-assisted computed tomography (CT) techniques have improved the overall accuracy for pedicle screw placement, and has reduced complication rates. 2013;123(9):20992103. In this example, the surgeon replaced the misplaced screw prior to leaving the operating room, which arguably played a significant role in the jury ruling in favor of the defendant (surgeon). J Neurosurg Spine. government site. 38. 2019;19(7):12211231. Pedicle screw fixation is an effective but demanding method to treat various spinal disorders and is associated with a significant complication rate. 3. 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. Please try after some time. The aim of this study is to evaluate the accuracy of pedicle screw insertion in spondylitis tuberculosis kyphosis correction using a freehand technique. Two-dimensional (2D) fluoroscopy-guided percutaneous pedicle screw (PPS) placement is currently the most widely applied instrumentation for minimally invasive treatment of spinal injuries requiring stabilization. The instrumentation and bone graft were left in place in these patients (total infection rate, 2.7%). 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. Under the high-low agreement, Drs. Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. To evaluate the accuracy of pedicle screw placement using a novel classification system to determine potentially significant screw misplacement. In six patients (5.3%) with degenerative spine disease, the disc material had been removed. 2018;18(2):209215. 2013;34(6):699705. Nahed BV, Babu MA, Smith TR, Heary RF. Weinstein JN, Spratt KF, Spengler D, Brick C, Reid S: Spinal pedicle fixation: Reliability and validity of roentgenogram-based assessment and surgical factors on successful screw placement. pedicle screw: A rigid surgical implant used to stabilize adjacent spinal segments in spinal fusion surgery. 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. 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). 2011;365(7):629636. Mean amounts awarded SD to plaintiffs by jury trial (n = 13) versus settlement/arbitration (n = 7), adjusted for inflation as of April 2020. The total number of reoperations for MPS and patient clinical data were obtained from medical records at each hospital. Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. Each case was then carefully screened for relevance and sufficient data. The initial search using the terms above returned 3654 cases. At the lumbosacral area, breakage of a divergent screw of a Chopin block occurred on only one side with no loss of correction. In unstable injuries, the segments above and below the level of injury may have a different orientation of the pedicle trajectory due to . 14. The average followup was 35 months (range, 1851 months). 2014;20(2):196203. Clin Orthop 284:8090, 1992. Agarwal N, Gupta R, Agarwal P, et al. Pedicle screw placement is a common procedure. Yuan HA, Garfin SR, Dickman CA, Mardjetko SM: A historical cohort study of pedicle screw fixation in thoracic, lumbar and sacral spinal fusions. Spine (Phila Pa 1976). 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. First, this is a retrospective analysis of cases obtained from the web-based Westlaw Edge legal research database. 11. J Spinal Disord Tech. 2018;28(2):186193. Defensive medicine in U.S. spine neurosurgery. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. On April 6, a Union County, N.J., jury awarded a plaintiff $4.5 million over a botched spine surgery. Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison. Mason A, Paulsen R, Babuska JM, et al. In situ spine arthrodesis permits load sharing by the vertebral bodies, preventing fatigue failure of the implant. 23. Katonis, Pavlos MD*; Christoforakis, Joseph MD*; Aligizakis, Agisilaos C. MD*; Papadopoulos, Charalampos MD*; Sapkas, George MD, DSc**; Hadjipavlou, Alexander MD*. Problems in the instrumented segments were considered those occurring from narrowing of the disc space greater than 3 mm, pseudarthrosis, and loss of reduction. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the . 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. 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. J Bone Joint Surg 62A:13021307, 1980. 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. Surg Neurol. Spine (Phila Pa 1976). Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. 2012;89(10):7071. Accuracy of C2 pedicle screw placement using the anatomic freehand technique. One hundred twelve patients were treated using the Cotrel-Dubousset pedicle screw fixation system for degenerative disease (57 patients), trauma (42 patients), infection (eight patients), and tumor (five patients) of the lumbar or thoracolumbar spine. Medical malpractice litigation has made a significant impact on spine surgery, with many spine surgeons avoiding complex cases or practicing other defensive medicine tactics in an effort to avoid being sued.5 Moreover, the majority of neurosurgeons spend more than 10% of their annual revenue on malpractice insurance,1,14 and the excessive financial risk of litigation is even leading some insurers to no longer offer coverage to spine surgeons.19 A 2011 study in the New England Journal of Medicine found that 19.1% of neurosurgeons are named as a defendant in a malpractice suit each year (highest of any specialty).12 Moreover, 88% of physicians in high-risk specialties, like neurosurgery, are involved in a lawsuit by age 45, increasing to a concerning 99% by 65 years of age.12 Such litigation places a substantial financial, temporal, and emotional burden on physicians in high-risk specialties, with studies showing that up to 72% of neurosurgeons1 admitted that their fear of litigation significantly influenced their practice,25 with many avoiding high-risk patients altogether.1 Similarly, Nahed et al. Sarwahi V, Ayan S, Amaral T, Wendolowski S, Gecelter R, Lo Y, Thornhill B. Spine Deform. Br J Neurosurg. leg pain. Both issues represent the most frequent and highest payouts in spine malpractice claims.10,14,22 While several studies have explored many of the factors related to malpractice claims in spine surgery, the medicolegal impact of misplaced pedicle and/or lateral mass screws has not been directly reported in the literature. Defensive medicine in neurosurgery: the Canadian experience. Pullout performance comparison of pedicle screws based on cement The defense pointed to the lack of evidence that the screw had ever come into contact with the L5 nerve root. 2014;21(3):320328. However, 5-10% of those misplaced screws are cause for concern." "To rectify this, we must have access to imaging devices during the procedure. The screws were needed to stabilize the spine and fix the fused vertebrae in place. Insuring spinal neurosurgery. 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. single homes for sale in lehigh valley, pa The medicolegal landscape of spine surgery: how do surgeons fare? Jury awards $4.5M over misplaced pedicle screw during spine surgery: 5 pedicle screws sagittal alignment spinal fusion surgical guides Spinal fusion is used to treat a range of conditions associated with spinal column such as intervertebral disc degeneration and scoliosis [ 1 ]. In White AH, Rothman RH, Ray CD (eds). Five patients had uneventful early postoperative course. There were two complete degenerations of the upper disc, one central canal stenosis, and two asymptomatic disc space narrowings and retrolistheses. Of note, while only 38.2% (n = 26) of cases in our study mentioned the use of intraoperative radiographic confirmation, only one of these cases reported that the misplaced screw had been caught prior to leaving the operating room, which had resulted in an inadvertent dural tear and L5 nerve root injury. In the remaining patients, the standard construct was three-segment fixation spanning four vertebrae and three discs, two above and one below the fractured vertebra, using six screws. 2002;27(22):24252430. 4. In the other patient, L4L5 float arthrodesis was done. It is an effective procedure in that it provides an almost immediate stabilization of the spine [ 2-5 ]. Minimizing Pedicle Screw Pullout Risks: A Detailed Biomechan The medicolegal landscape of spine surgery: how do surgeons fare? sharing sensitive information, make sure youre on a federal As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiff's spine. Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). A rod is used to hold the vertebra together to allow fusion to occur. Clin Orthop 203:7598, 1986. Clin Orthop 115:130139, 1976. In several of the studies in the spinal literature, the contention that instrumentation improves arthrodesis rates, considering that nonunion contributes to a poor outcome in spinal arthrodesis is favored. 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. HHS Vulnerability Disclosure, Help 25. Please enable it to take advantage of the complete set of features! Fishers exact test and the Mann-Whitney U-test were used for the analysis of categorical and continuous data, respectively, except when an unpaired t-test was utilized for analyses related to normalized, nominal, and inflation-adjusted award totals. Are We Underestimating the Significance of Pedicle Screw Misplacement Two patients with associated injuries in the lower limbs had deep venous thrombosis develop, three patients had pneumonia develop, and four patients with neurologic impairment had urinary tract infections develop. 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. Additional survey data have shown that 50% of physicians exhibit at least a temporary loss of self-esteem after a malpractice claim, and at least 25% experience depression.22 As stated above, the average neurosurgeon spends 27.2% of his or her entire career in an open malpractice claim,10 and each case can take an average of 5.1, 5.0, and 3.4 years for defendant verdicts, plaintiff rulings, and settlements, respectively.7,15 Likewise, neurosurgeons have a higher risk than practitioners in other specialties of being named in multiple malpractice suits given the particularly high-risk nature of the specialty.10 Even when found in favor of the defendant (surgeon), each case ultimately takes a substantial emotional and financial toll on the physician(s) involved. Eur Spine J. 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. Edwards CC: Spinal screw fixation of the lumbar and sacral spine: Early results treating the first 50 cases. Don't jump in get legal help. The defendants explanation provided an explanation for why Nyquists foot drop did not resolve after the misplaced screw was removed and shed doubt on the plaintiffs theory of liability. The amount awarded was not significantly different across US regions (p = 0.9; Fig. A retrospective review of charts, x-rays (XRs) and computed tomography (CT) scans was performed. your express consent. Spine fixation included one segment in 27 patients, two segments in 38 patients, three segments in 42 patients, and more than three segments in five patients. Federal government websites often end in .gov or .mil. Malpractice litigation following spine surgery. 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. Pedicle Screw Insertion in Spondylitis Tuberculosis | ORR Linking and Reprinting Policy. The medical malpractice suit Ayala v. Friedlander, M.D., claimed that a March 2011 lumbar fusion surgery performed by neurosurgeon Marvin Friedlander, MD, and orthopedic spine surgeon Douglas Bradley, MD, strayed from the accepted standards of care because a pedicle screw was placed in the wrong location. 2. Pedicle Screw Malposition Expert Witness: Malposition Can Lead to Reoperation for Misplaced Pedicle Screws: A Multicenter Retrospec and 17.1% of the patients included had at least one screw misplaced. Rothberg MB, Class J, Bishop TF, et al. (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. Disc space narrowing was the most common problem after instrumented arthrodesis and was observed in 27 patients (24.1%). $ = US$; MW = Midwest; NE = Northeast; SE = Southeast; SW = Southwest; W = West. Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants Irwin v. Alan Loren, M.D. Spinal fusion procedures are increasingly performed each year, with Deyo et al. 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). J Spine Surg. Abstract BACKGROUND CONTEXT Surgeons have increasingly adopted robotic-assisted lumbar spinal fusion due to indications that robotic-assisted surgery can reduce pedicle screw misplacement. 15. 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. Wiltse LL, Spencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. 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. 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. As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiffs spine. Malpractice claims in spine surgery in Germany: a 5-year analysis. From the *Department of Orthopaedic Surgery, University of Crete Medical School, Heraklion, Greece; and the **First Department of Orthopaedics, University of Athens Medical School, Athens, Greece. Epstein NE. The third surgical procedure removed the pedicle screws but left the patient in an unfused state with an unstable spine. Review of neurosurgery medical professional liability claims in the United States. The cost of defensive medicine on 3 hospital medicine services. Nyquist had requested the defendants offer, which in retrospect was perhaps a poor decision in light of the Kane County jurys verdict. When adjusted for inflation, these values increased to $1,330,201 $882,023 versus $970,832 $381,619, respectively (p = 0.32; Fig. single homes for sale in lehigh valley, pa single homes for sale in lehigh valley, pa Home Realizacje i porady Bez kategorii single homes for sale in lehigh valley, pa Spine 17:834837, 1992. 15. Eur Spine J. $ = US$. J Bone Joint Surg 45A:11591170, 1963. Crawford MJ, Esses SI: Indications for pedicle fixation: Results of NASS/SRS faculty questionnaire: North American Spine Society and Scoliosis Research Society. Problems of balance were coronal (scoliosis greater than 5 or trunk shift greater than 5 mm) as seen on the AP radiograph taken with the patient standing or sagittal (failure to obtain or maintain lumbar lordosis). Neurological outcome and management of pedicle screws - PubMed Patient-specific 3D-printed surgical guides for pedicle screw insertion Autor de la entrada Por ; Fecha de la entrada austin brown musician; matrix toners for bleached hair . Hadjipavlou A, Enker P, Dupuis P, Katzman S, Silver J: The causes of failure of lumbar transpedicular spinal instrumentation and fusion: A prospective study. Jury Verdict for Doctor for Screw Allegedly Misplaced During Lumbar 22. 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. Intraoperative pedicle fractures requiring further points of fixation. Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. 2005;293(21):26092617. It should be used by experienced and qualified surgeons who are familiar with the pitfalls associated with its use. 13. In two patients in the current series, dislodgement of the rods from tulip screws occurred, as reported originally by Edmunds et al. Ahmadi SA, Sadat H, Scheufler KM, et al. Reviewed submitted version of manuscript: all authors. JAMA Intern Med. A TLIF is a surgical procedure that attempts to fuse vertebrae in order to stabilize the patient's spine. The patient had to undergo a subsequent surgery to remove the pedicles. Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws. 33. This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. Spine 18:983991, 1993. Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. 2016;25(3):716723. Partner, Paul M. da Costa, Obtains $4.5 Million Verdict - Snyder Sarno Makhni MC, Park PJ, Jimenez J, et al. 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. Krag MH, Beynnon BD, Pope MH, et al: An internal fixator for posterior application to short segment of the thoracic, lumbar, or lumbosacral spine. Steinmann JC, Herkowitz HN: Pseudarthrosis of the spine. 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. Risk Factors for the Drift Phenomenon in Oarm NavigationAssisted 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. Patient Suffers Permanent Nerve Damage From Spinal Surgery The rate of medical complications was 8%. 2017 Mar;5(2):109-116. doi: 10.1016/j.jspd.2016.10.007. 2013;32(1):111119. Methods. 144 28. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. 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. Jury awards $4.5M over misplaced pedicle screw during spine surgery: 5 things to know Spine Monday, May 7th, 2018 Post Listen Text Size On April 6, a Union County, N.J., jury awarded a plaintiff $4.5 million over a botched spine surgery. Spine 18:18621866, 1993. The rate of reoperation for screw misplacement per screw was 0.17%. Mukherjee S, Pringle C, Crocker M. A nine-year review of medicolegal claims in neurosurgery. Pedicle screw placement: Robotic assistance for greater precision 4. Before PDF Intraoperative biomechanics of lumbar pedicle screw loosening following Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. Spine 18:11601172, 1993. Achieving proper lumbar lordosis, evaluating any preexisting scoliosis, and intraoperative assessment with AP radiographs could prevent balance problems. 8. 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. In patients with degenerative conditions, all of the affected segments were included in the instrumentation and each vertebra was fixed with two pedicle screws. Lumbar Spine Surgery. Nottmeier EW, Seemer W, Young PM. In their meta-analysis of nine randomized controlled trials, Li et al. Spine 18:23252326, 1993. 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 Johnston II CE, Ashman RB, Baird AM, Allard RN: Effect of spinal construct stiffness on early fusion mass incorporation: Experimental study. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. All these problems were observed only just above the upper instrumentation level and all were observed in patients older than 55 years. It has a great developing technique that is used for fixation and fusion in spine surgery.