Another possible cause was the high lateral torques to the entire frame that occurred during tightening of the tulip screw. Dr. K. D. Than is a consultant for Bioventus and receives honoraria from DJO and LifeNet Health. 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. Spine (Phila Pa 1976). Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation Nickl v. Barry S. Rosen, M.D. 2018;28(2):186193. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. 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. Please enable scripts and reload this page. J Neurosurg Spine. South Med J 62:17, 1969. JAMA. In our opinion, these problems may be prevented by applying the following principles: limitation of spine arthrodesis to the pathologic levels, inclusion of already extensive changes at the level above or below the planned arthrodesis into the arthrodesis, restoration of postoperative sagittal and coronal alignment, and avoidance of impingement syndrome from the adjacent nonfused facets. 2014;174(11):18671868. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. 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. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. All Rights Reserved. Clin Orthop 115:130139, 1976. Several limitations should be carefully considered when interpreting our results. Taylor CL. 4). Schlegel JD, Smith JA, Schleusener RN: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Eur Spine J. In addition, seven (6.3%) dural tears occurred during the decompression and none occurred during instrumentation. Spine 6:615619, 1981. Retrospective analysis of reasons and revision strategy for failed thoracolumbar fracture surgery by posterior approach: a series of 31 cases. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. pedicle screw misplacement malpractice. Please enable it to take advantage of the complete set of features! 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. 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. Reprint requests to Pavlos Katonis, MD, 99 Minoos & Thenon Street, 71305, Heraklion, Crete, Greece. NCI CPTC Antibody Characterization Program. Call me tomorrow. MeSH Copyright 1944-2023 American Association of Neurological Surgeons, Copy this link, or click below to email it to a friend. 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. Spine (Phila Pa 1976). Under the high-low agreement, Drs. Malpractice claims in spine surgery in Germany: a 5-year analysis. A rod is used to hold the vertebra together to allow fusion to occur. 2018;43(14):984990. Achieving proper lumbar lordosis, evaluating any preexisting scoliosis, and intraoperative assessment with AP radiographs could prevent balance problems. doi: 10.1097/BRS.0b013e31822a2e0a. 19. The physician ordered an MRI of the lumbar spine which showed that the screws had been misplaced and were puncturing the patient's lumbar nerves. Results: A total of 2724 screws were placed in 127 patients. 144 Unfortunately, the plaintiffs attorney was unable to offer an alternative theory of surgical negligence that would refute the defendants explanation. J Neurosurg Spine. However, despite the apparent widespread use of pedicle system fixation, few studies of problems and particularly complications have been published. Spinal fusion procedures are increasingly performed each year, with Deyo et al. Epub 2014 Apr 4. 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. Pedicle screw placement is a common procedure. Spine 18:983991, 1993. However, the highest offer had been a combined $300,000 from the two defendants. Although the rationale for using pedicle screw fixation is fairly clear, controversy continues regarding the application of pedicle instrumentation for spine arthrodesis, especially on the degenerative lumbar spine. 2016;102(2):358362. Median screw misplacement rate was 10% in group A and 13% in group B. 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 Both of these patients complained of thigh pain but refused any additional surgery. 2 One of the first obstacles regarding . 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. Epstein NE. 1. 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. Review of neurosurgery medical professional liability claims in the United States. The medicolegal landscape of spine surgery: how do surgeons fare? (A) Anteroposterior and (B) lateral radiographs show coronal imbalance that developed 4 years after surgery in a 57-year-old woman with L3L4 float fusion. Spine (Phila Pa 1976). 2017;27(4):470475. Neurologic injury. To investigate intraoperative reinsertion of percutaneous pedicle screw (PPS) with intraoperative CT-based navigation and to evaluate the rate of deviation of PPS at postoperative radiographic examination. Pedicle screw placement safety with the aid of patient-specific guides in a case series of patients with thoracic scoliosis. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the . JAMA. (A) Anteroposterior and (B) lateral radiographs taken 2 years after surgery show unilateral pseudarthrosis in a 55-year-old man with spinal stenosis. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. 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. Facebook Google Plus Youtube RSS Email. Spine 13:696706, 1988. Fager CA. Introduction. 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). 2. 23. Examples of both laterally and medially misplaced lumbar pedicle screws are provided in Fig. However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. 2002;27(22):24252430. Potential complications may include increased pain, infection, or mechanical . Schatlo B, Molliqaj G, Cuvinciuc V, et al. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? Bethesda, MD 20894, Web Policies Careers. J Neurosurg Spine. 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. 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%. Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. Among the plaintiff-awarded cases, 13 (61.9%) were decided by jury trial, 7 (33.3%) by settlement, and 1 (4.8%) by arbitration. J Bone Joint Surg 73A:11791184, 1991. FOIA The initial search using the terms above returned 3654 cases. The authors of the current study aimed to describe this impact in the United States, as well as to suggest a potential method for mitigating the problem. 2018;83(5):9971006. 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. Dr. Abd-El-Barr is a consultant for Spineology. Spine (Phila Pa 1976). 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. HHS Vulnerability Disclosure, Help Li HM, Zhang RJ, Shen CL. A.J. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. Defensive medicine: a culprit in spiking healthcare costs. 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. Studdert DM, Mello MM, Sage WM, et al. The median time to case closure was 56.3 (35.267.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.477.2) months for defendant (surgeon) verdicts (p = 0.117). One hundred four of the 112 patients had a posterior procedure. Plaintiff award amounts were adjusted for inflation as of April 2020 using an online inflation calculator provided by the US Bureau of Labor Statistics (https://www.bls.gov/data/inflation_calculator.htm). Nevertheless, research has shown that screws are misplaced in approximately 14%55% of cases using the standard techniques (freehand and 2D fluoroscopic guidance) employed by most spine surgeons,21,33 resulting in injury in approximately 1%8% of cases.21 In addition to the avoidable procedural risk to the patient, each misplaced screw carries the threat of future litigation, as reported above. Spine 18:18621866, 1993. This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. A total of 247 screws (9.07%) were BMP, 52 (1.91%) were IMP, and 29 (1.06%) were considered SAR. The plaintiff received $2.4 million for pain and suffering and loss of enjoyment of life, $2 million for lost income and approximately $123,000 for medical expenses. 5. 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). The jury found the defendants liable and allocated 75 percent of the fault to Dr. Friedlander and 25 percent to Dr. Bradley. Koktekir E, Ceylan D, Tatarli N, Karabagli H, Recber F, Akdemir G. Spine J. Pedicle screws have been used to treat spinal disorders, including those caused by spinal cancer, congenital anomalies, trauma, and chronic pain syndromes. This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. 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. 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). Rothberg MB, Class J, Bishop TF, et al. laterally placed screws and the azygous vein on the right (T5-T11). EOS System Courtesy of EOS imaging.
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