While wrong-site spinal surgeries are rare, the ramifications of a mistake can be devastating for patients, providers and health systems.
Rochester, Minn.-based Mayo Clinic is taking systemwide action to minimize these risks, by developing an “ironclad” process to make sure wrong-site mistakes never happen, according to a June 20 news release.
Mayo’s processes are used both for spinal surgeries and for minimally invasive nonsurgical spinal interventions, such as selective nerve root blocks.
“Even one wrong-level spine procedure is more than unacceptable,” Chandan Krishna, MD, a neurosurgeon at Mayo Clinic in Phoenix/Scottsdale, Ariz., said in the release. “We think that the incidence of wrong-level spinal procedures is likely underreported in the literature.”
While around 90% of the population has normal spinal segmentation, 10% has a variant anatomy that changes conventional numbering of the spinal vertebrae. Changes like this can lead to surgical errors. Other anomalies, like having an extra rib, can also lead to disparate numbering of the thoracic vertebrae.
At systems as large as Mayo, it is not uncommon to see patients with disparate spinal anatomy. The system aims to avoid any errors by using a multidisciplinary approach, having several different types of specialists present for every case, including neurosurgeons, neurologists, neuroradiologists, orthopedic surgeons and pain-medicine providers.
Mayo Clinic’s spinal imaging also standardizes labeling among all types of specialists. Initial spine localizer imaging is numbered, and the numbered image is archived for reference by all healthcare providers. All providers are also required to complete detailed clinical and surgical notes that begin with a clear description of any transitional anatomy.
Mayo also standardizes its process by applying the same labeling process to imaging performed elsewhere that patients bring with them to Mayo Clinic.
During the actual procedure, Mayo surgeons take additional steps to mitigate problems by performing an intraoperative timeout, in addition to the standard presurgical pause. Intraoperative CT is also used, particularly during challenging procedures, such as when a patient has obesity. Intraoperative CT allows physicians to see all of a patient’s anatomy, eliminating any guesswork.
Specialists at Mayo are also in constant collaboration, meeting regularly in a multidisciplinary spinal conference to discuss complex cases.
