doi: 10.1097/BRS.0b013e31822a2e0a. Neurological Outcome and Management of Pedicle Screws Misplaced Totally 8,24,25,32. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. Kreisman Law Offices has been handling Illinois surgical error lawsuits for individuals and families for more than 35 years in and around Chicago, Cook County and surrounding areas, including Batavia, Bellwood, Deerfield, Evanston, Franklin Park, and Lansing. The third surgical procedure removed the pedicle screws but left the patient in an unfused state with an unstable spine. demonstrated that the number of hospital discharges for spinal fusion increased 2.4 times (137%) from 174,223 to 413,171 (p < 0.001) between 1998 and 2008.32 The true frequency of malpositioned pedicle and lateral mass screws is likely underestimated in spine surgery given the fact that the majority of misplaced screws, as well as the potential complications related to them, are not reported in practice and may be clinically silent. The highly litigious environment within healthcare has resulted in a majority of physicians practicing defensive medicine,15 often leading to burnout6,7 and an exorbitant ethical and financial burden on medical and surgical care.7,8 In 2008, medical liability accounted for $55.6 billion, representing 2.4% of the United States (US) healthcare expenditures that year,5,7,9,10 and the pervasive practice of defensive medicine may cost up to $210 billion annually in the US.5 A similar trend has been observed in Europe.11, Neurosurgery is the specialty most frequently affected by lawsuits and the fear of litigation, both in the US and abroad,12 with spine surgery at the forefront.11,1317 As a result, spine surgeons are nearly three times more likely than nonspine surgeons to practice defensive medicine, defined as the avoidance of high-risk procedures and the provision of unnecessary services and assessments beyond what is clinically necessary in an effort to avoid litagation.5 The average time to judgment in a case is approximately 5.1, 5.0, and 3.4 years for defendant verdicts, plaintiff rulings, and settlements, respectively.7,15 As a result, physicians spend an average of 11% of their careers dealing with one or more open malpractice claims.18 Neurosurgeons are especially impacted, spending an average of 27.2% of their careers in an open lawsuit.10. 5-7 Materials and Methods This is a retrospective study of kyphotic spondylitis tuberculosis (Stb) patients conducted at Fatmawati General Hospital, Jakarta, Indonesia, through the year 2020-2021. 70% of Pedicle Screws are misplaced - orthostreams.com $ = US$. In five patients with thoracolumbar injuries, who were the first treated in the current series, and in four patients with fractures in the lower lumbar spine, two-segment fixation was used. Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement Screws penetrating the anterior cortex and abutting vascular structures, particularly aortic abutment with left-sided screws, which can lead to erosion and pseudoaneurysms. 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). 0 attorneys agreed. The most frequent primary injury listed for a lawsuit was nerve root injury, present in 81.0% (n = 17) and 74.5% (n = 35) of plaintiff- and defendant-awarded cases, respectively (p = 0.7). Jury Verdict for Doctor for Screw Allegedly Misplaced During Lumbar Edmunds I, Cummine J, Fearnside M: Prevention of dislodgement of Cotrel-Dubousset rods from tulip screws. Long spine fixation was necessary for patients with tuberculous spondylitis and metastatic disease. 2011;24(1):1519. Adjusted for age and preoperative Cobb angle, patients with a higher misplacement rate were more likely to have screws . Drafting the article: Sankey. 2. Fager CA. Rothberg MB, Class J, Bishop TF, et al. What can spine surgeons do to improve patient care and avoid medical negligence suits? 2014;20(6):636643. Of note, the award amount for one settlement case was undisclosed. Can Postoperative Radiographs Accurately Identify Screw Misplacements? Neurologic injury. Wiltse LL, Spencer CW: New uses and refinements of the paraspinal approach to the lumbar spine. 2013;123(9):20992103. Screw Malposition: Are There Long-term Repercussions to Malposition of Pedicle Screws? 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). Jury awards $4.5M over misplaced pedicle screw during spine surgery: 5 Although the rate of the reported medical complications was high (36.5%), these did not significantly affect the final clinical outcome of the current patients. In the current series, including general complications, only 48 patients (43%) had no notable complication and the remaining 64 patients (57%) had one or more complications. Federal government websites often end in .gov or .mil. J Neurosurg. 2022 Dec;31(12):3544-3550. doi: 10.1007/s00586-022-07427-0. Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. Dr. Shaffrey holds patents with, receives royalties from, and is a consultant for Medtronic, NuVasive, and Zimmer Biomet; is a stockholder in NuVasive; is a consultant for K2M, Stryker, SI Bone, and In Vivo; and has received grants from the ISSG, DePuy Synthes, and AO Spine. Epub 2014 Jun 13. 17,18,31,39 Edwards 6 showed that solid arthrodesis developed in 96% of patients without previous surgery, whereas 84% of patients having secondary operations experienced a similar result. Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary? Drs. 3,4,9,29,34 In addition, developments in surgical technique and implant design have decreased operative risk and implant-related complications. Hecht N, Kamphuis M, Czabanka M, et al. These risks can be minimized by the judicious use of instrumentation by experienced surgeons for specific indications as supported by the literature. The initial search using the terms above returned 3654 cases. 2020;162(6):13791387. 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. Study supervision: Goodwin, Karikari, Shaffrey, Abd-El-Barr, KD Than. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. Axial lumbar CT scans demonstrating both laterally (right) and medially (left) misplaced pedicle screws, resulting in pedicle and transverse process fractures (A) and canal compromise (A and B). In addition, the median time to judgment is substantial, particularly for defendant verdicts, spanning over 4.5 years from the time of surgery. To evaluate the accuracy of pedicle screw placement using a novel classification system to determine potentially significant screw misplacement. GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). Pedicle screw placement: Robotic assistance for greater precision Surg Neurol Int. All of these patients were asymptomatic and had satisfactory final clinical outcomes (Fig 2). 2014 Aug 1;14(8):1702-8. doi: 10.1016/j.spinee.2014.03.044. Litigation resulted in average payouts of $1,204,422 $753,832 between 1995 and 2019, when adjusted for inflation. 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. pedicle screw misplacement malpractice. Your message has been successfully sent to your colleague. South Med J 62:17, 1969. Delayed open treatment of aortic penetration by a thoracic pedicle To reinforce spinal fixation, we have proposed a construct with segmental pedicle fixation two levels above and one level below the injured level and insertion of a screw deep into the pedicle, providing more contact area between screw head and bone and reducing the moment arm of the bending stress. Pullout performance comparison of pedicle screws based on cement Pedicle screw insertion techniques: an update and review of the Start; O firmie; Usugi; Serwis; Realizacje i porady; Kontakt Reprint requests to Pavlos Katonis, MD, 99 Minoos & Thenon Street, 71305, Heraklion, Crete, Greece. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. J Spine Surg. Reviewed submitted version of manuscript: all authors. 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. Dr. Abd-El-Barr is a consultant for Spineology. CT-navigation versus fluoroscopy-guided placement of pedicle screws at Accuracy of C2 pedicle screw placement using the anatomic freehand technique. 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Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis. 24. J Neurosurg Spine. Smith TR, Hulou MM, Yan SC, et al. This step in implant evolution was inevitable, because prior phases of implant development did not control each plane of motion segment stress. 25. Schlegel JD, Smith JA, Schleusener RN: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. The case facts centered on a spinal surgery the 34 year-old plaintiff had undergone at Central DuPage Hospital. Taylor CL. 5 Those authors recommend that particular care should be taken in inserting the washers without cross threading and ensuring that they are locked down tightly, with an adequate length of rod protruding beyond the screw. Bydon M, Xu R, Amin AG, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Zucherman J, Hsu K, Picetti III G, et al: Clinical efficacy of spinal instrumentation in lumbar degenerative disc disease. The plaintiff underwent revision surgery in May 2013. 4. 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%). Defensive medicine in neurosurgery: the Canadian experience. 20 Tips to Avoid and Handle Problems in the Placement - ScienceDirect 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. Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. 2021 Jul 1;41(Suppl 1):S80-S86. Bookshelf 2014 Sep;21(3):320-8. doi: 10.3171/2014.5.SPINE13567. 3. Pediatric pedicle screw placement using intraoperative computed tomography and 3-dimensional image-guided navigation. Malpractice liability and defensive medicine: a national survey of neurosurgeons. 1. 21. Nahed BV, Babu MA, Smith TR, Heary RF. You are talking one of the most complicated area of the law. Author links open overlay panel Mohamad Bydon a b 1, Dimitrios Mathios a b 1, Mohamed Macki a b, Rafael De la Garza-Ramos a b, Nafi Aygun c, Daniel M. Sciubba a, Timothy F. Witham a, Ziya L. Gokaslan a b, Ali Bydon a b, Jean-Paul Wolinksy a. Each case was then carefully screened for relevance and sufficient data. Critically revising the article: all authors. 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). Pitfall: Unstable injuries. Conclusion: Risk Factors for the Drift Phenomenon in Oarm NavigationAssisted Accuracy of C2 pedicle screw placement using the anatomic freehand Bydon M, Xu R, Amin AG, et al. 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. A total of 2724 screws were placed in 127 patients. The instrumentation and bone graft were left in place in these patients (total infection rate, 2.7%). Pullout strength of misplaced pedicle screws in the thoracic and lumbar Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. 2,24,28,36. J Neurosurg Spine. Spine 13:952953, 1988. Spine 18:983991, 1993. 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. Breakage of a divergent screw of a Chopin block at the lumbosacral area was seen 3 months after surgery. Copyright 2023 Becker's Healthcare. Health Aff (Millwood). Preparation. All these problems were observed only just above the upper instrumentation level and all were observed in patients older than 55 years. 2014;96(4):266270. The .gov means its official. Misplaced pedicle and lateral mass screws result in a considerable risk of malpractice litigation against spine surgeons. N Engl J Med. Twenty-one patients (18.8%) had thoracolumbar injuries, and loss of immediate postoperative deformity correction ranged from 1.4 to 4.5. A retrospective review of closed medicolegal cases with verdicts or settlements between 1995 and 2019 was performed using the Westlaw Edge legal research database (Thomson Reuters).7,14,16,23,24 A search of closed federal and state malpractice claims within the Verdicts and Settlements section consisted of the following: spine and surgery and pedicle and screw and fusion and (misplaced or misguided or mispositioned) and surgeon. Inclusion criteria consisted of malpractice claims against surgeons for complications related to misplaced pedicle and/or lateral mass screws. Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. It is an effective procedure in that it provides an almost immediate stabilization of the spine [ 2-5 ]. Elizabeth Hofheinz, M.P.H., M.Ed. Copyright © 2023 Becker's Healthcare. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. 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). 7. Clin Orthop 227:1023, 1988. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. The amount awarded was not significantly different across US regions (p = 0.9; Fig. 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. leg pain. Excessive hemorrhage occurred in two patients (1.8%) with coagulation disorders. Importantly, these advanced technologies are not always readily available or the standard of care and cannot supplant a thorough understanding of operative anatomy, a high-quality surgical technique, and general complication-avoidance measures. Under the high-low agreement, Drs. Disclosures Dr. Karikari is a consultant for NuVasive, Globus, Johnson & Johnson, and DePuy and receives a spine fellowship fund from NuVasive. Katonis, Pavlos MD*; Christoforakis, Joseph MD*; Aligizakis, Agisilaos C. MD*; Papadopoulos, Charalampos MD*; Sapkas, George MD, DSc**; Hadjipavlou, Alexander MD*. 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. Quraishi NA, Hammett TC, Todd DB, et al. NCI CPTC Antibody Characterization Program. Agarwal N, Gupta R, Agarwal P, et al. Balch CM, Oreskovich MR, Dyrbye LN, et al. Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. Roy-Camille R, Roy-Camille M, Demeulenaere C: Osteosynthese du rachis dorsal, lombaire et lombo-sacre par plaque metalliques vissees dans les pedicules vertebraux et es apophyses articularies. J Bone Joint Surg 73A:11791184, 1991. Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws. pedicle screw misplacement malpractice 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. Ann Thorac Surg. 2006;65(4):416421. 2018;41(5):e615e620. Spine 17:349355, 1992. Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Nationally Recognized Regionally Dominant Contact Us Now For a Free Consultation Over $850 Million in Verdicts and Settlements Home Articles Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Krag MH, Beynnon BD, Pope MH, et al: An internal fixator for posterior application to short segment of the thoracic, lumbar, or lumbosacral spine. Grubb SA, Lipscomb HJ: Results of lumbosacral fusion for degenerative disc disease with and without instrumentation: Two- to five-year follow-up. 27. 1 To be effective, the pedicle screw constructs must withstand intraoperative loading and physiological forces due to daily postoperative activities. A total of 247 screws (9.07%) were BMP, 52 (1.91%) were IMP, and 29 (1.06%) were considered SAR. 36. What can spine surgeons do to improve patient care and avoid medical negligence suits? 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. 3). JAMA. 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. The defense pointed to the lack of evidence that the screw had ever come into contact with the L5 nerve root. Several studies reveal that fusion rates increase when rigid internal fixation is used, 14,20,21,33,38 and that by using pedicle screws and plates or rods for stabilization, spinal arthrodesis can be limited to the disease segments. Using chi square analysis, statistically significant correlation was seen between disc space narrowing and loss of postoperative correction (p < 0.01). The rate of reoperation for screw misplacement per screw was 0.17%. The radiology results showed that the surgical screw placed at the right L4-5 area had breached the medial wall and was actually extending into the spinal canal. In the current study, the arthrodesis rate of 89.4% compares favorably with other previously reported series in the spinal literature, most of which use radiographic means to access the status of the spinal arthrodesis. Unauthorized use of these marks is strictly prohibited. J Spinal Disord Tech. 34. A rod is used to hold the vertebra together to allow fusion to occur. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. Data is temporarily unavailable. Pedicle screw placement is a common procedure. Thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. Thoracic Pedicle Screws - ScienceDirect A total of 69 patients (mean age, 67.416 . 2012;21(suppl 2):S196S199. Guillain A, Moncany AH, Hamel O, et al. These numbers are in line with the current literature. 5. Finally, considering the problems of balance, it seems that failure to properly evaluate any preexisting scoliosis was a main cause of this important complication. Once the spine is exposed, the appropriate levels of fixation are confirmed with the image intensifier. However, the misplacement of pedicle screws can lead to disastrous complications because of the close proximity to neural tissue and the surrounding vessels, although rare, serious complications have been reported, such as dural tear, nerve-root irritation, neural injury . 2017;27(4):470475. Clin Orthop 203:4553, 1986. In the Kane County medical malpractice lawsuit of Melissa Nyquist v. Dr. Taras Masnyk and DuPage Neurosurgery, S.C., 06 L 421, the plaintiffs attorney was unable to convince the jury that the plaintiffs medical complications were caused by the defendants negligence. Pedicle Screw Insertion in Spondylitis Tuberculosis | ORR 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%. Problems in the instrumented segments were considered those occurring from narrowing of the disc space greater than 3 mm, pseudarthrosis, and loss of reduction. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating.