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Cervical ribs at C7. Plain antero-posterior radiographs demonstrate C7 vertebra bearing a pair of ribs, left larger than right, which cannot be considered thoracic because they do not articulate with the manubrium.

Cervical ribs at C7. Plain antero-posterior radiographs demonstrate C7 vertebra bearing a pair of ribs, left larger than right, which cannot be considered thoracic because they do not articulate with the manubrium.

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Wrong site surgery is one of five surgical "Never Events," which include performing surgery on the incorrect side or incorrect site, performing the wrong procedure, performing surgery on the wrong patient, unintended retention of a foreign object in a patient, and intraoperative/immediate postoperative death in an ASA Class I patient. In the spine,...

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... evaluation of the images revealed two abnormalities in the patient's vertebral seg- mentation that skewed our intraoperative counting of levels. First, the patient had a pair of cervical ribs at C7 ( Figure 3); second, the patient had only 11 pairs of thor- acic ribs (Figure 4). Thus, correct labeling of the patient's vertebrae showed that we performed posterior fusion from T5-T8 with decompression at the correct T7-8 pathologic level, even though intraoperatively we thought we were treating T6-T9. ...

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... Anatomical variations can compound an already significant problem where it has been suggested that an anatomical variation of 11 ribs is present in 3.4% of the population [20]. Furthermore, the presence of cervical ribs may also need to be accounted for, however, obtaining plain radiographs was not routine practice by the vast majority of surgeons responding to our survey [21]. Although some areas of practice showed significant consistency, with a large majority (> 80%) using fluoroscopy as the mainstay of level checks for both anterior and posterior spinal surgery. ...
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Background Current literature suggests that wrong-level spine surgery is relatively common with far-reaching consequences. This study aims to assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for correct level verification. Methods To assess the current practices of spinal surgeons across the UK with respect to the techniques implemented for level verification. The authors hypothesise the absence of a standardised technique used across spine surgeons in the UK. Practices amongst respondents will be ascertained via an electronic questionnaire designed to evaluate current practices of spinal surgeons whom are members of the British Association of Spinal Surgeons (BASS). The study data will include key information such as; the level of surgical experience, specific techniques used to perform level checks for each procedure and prior involvement with wrong-level spine surgery. Responses were collected over the period of 1 month with a reminder sent 2 weeks prior to closure of the survey. The data were collated and descriptive analyses performed on multiple-choice question answers and common themes established from free text answers. Results A total of 27% (n = 105/383) members responded. The vast majority had greater than 10 years’ experience. Intraoperative practices varied greatly with varying practices present for cervical, thoracic and lumbar level surgery. Only 38% (n = 40) of respondents re-checked the level intra-operatively, prior to instrumentation. Of the respondents 47.5% (n = 29/61) of surgeons had been involved in wrong level spinal surgery. Conclusion This study highlights the varying practices amongst spinal surgeons and suggests root cause for wrong-level spine surgery; where the level identified pre-incision was subsequently not the level exposed. We describe a novel safety-check adopted at our institute using concepts and lessons learnt from the WHO Checklist.
... 5 Anatomical variations and abnormalities have been identified as an important cause of wrong-level spine surgery. [5][6][7] Use of intraoperative fluoroscopy is the most common way of identifying the correct level, since depending on visible or palpable anatomical landmarks alone is not reliable. 8 In such a scenario, if the patient has unusual anatomy with an abnormal number of vertebrae that is not recognized before the surgery, intraoperative counting using fluoroscopy is prone to error and may lead the surgeon to a wrong level. ...
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Background: Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve. Methods: Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients' gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae. Results: Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae. Conclusions: There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient's preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels. Level of evidence: 3. Clinical relevance: Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS.
... It has been characterized as wrong-site surgery, and the Joint Commission on Accreditation of Healthcare Organization (JCAHO) reported that wrong-site surgery was the most common sentinel event in 2008 [1,2]. The cervical spine is the second most common location in the spine at which surgery is performed at the wrong level [3,4], and its incidence ranges from 0.09 to 4.5 per 10,000 surgeries performed. In one survey involved 415 spine surgeons, 217 responded that they had performed, at least once, wrong-level surgery during their career [4]. ...
... In those patients where difficulty in counting levels is anticipated, interventional radiology can place fiducial markers preoperatively [21]. Advanced fiducial markers, including percutaneous fiducial screws and skin adhesive radio-opaque grid lines, have also been shown to improve the accuracy of spinal level localization [3,22,23]. ...
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Spine surgery at the wrong level is an adversity that many spine surgeons will encounter in their career, and it falls under the wrong-site surgery sentinel events reporting system. The cervical spine is the second most common location in the spine at which surgery is performed at the wrong level. Anatomical variations of the cervical spine are one of the most important incriminating risk factors. These anomalies include craniocervical junction abnormalities, cervical ribs, hemivertebrae, and block/fused vertebrae. In addition, patient characteristics, such as tumors, infection, previous cervical spine surgery, obesity, and osteoporosis, play an important role in the development of cervical surgery at the wrong level. These were described, and several effective techniques to prevent this error were provided. A thorough review of the English-language literature was performed in the database PubMed between 1981 and 2019 to review and summarize these risk factors. Compulsive attention to these factors is essential to ensure patient safety. Therefore, the surgeon must carefully review the patient's anatomy and characteristics through imaging and collaborate with radiologists to reduce the likelihood of performing cervical spine surgery at the wrong level.
... In addition, comorbid conditions such as obesity and osteoporosis should be identified in patients undergoing surgery. In those patients where difficulty in counting levels is anticipated, interventional radiology can place fiducial markers preoperatively [18,[19][20][21]. Advanced fiducial markers, including percutaneous fiducial screws and skin adhesive radio-opaque grid lines, also have been shown to improve the accuracy of spinal level localization [19][20][21]. ...
... In those patients where difficulty in counting levels is anticipated, interventional radiology can place fiducial markers preoperatively [18,[19][20][21]. Advanced fiducial markers, including percutaneous fiducial screws and skin adhesive radio-opaque grid lines, also have been shown to improve the accuracy of spinal level localization [19][20][21]. Another preoperative technique described is placing polymethylmethacrylate into the vertebral body percutaneously using standard vertebroplasty [19,22]. ...
... Advanced fiducial markers, including percutaneous fiducial screws and skin adhesive radio-opaque grid lines, also have been shown to improve the accuracy of spinal level localization [19][20][21]. Another preoperative technique described is placing polymethylmethacrylate into the vertebral body percutaneously using standard vertebroplasty [19,22]. ...
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Spine surgery at the wrong level is a detrimental ordeal for both surgeon and patient, and it falls under the wrong-site surgery sentinel events reporting system. While there are several methods designed to limit the incidence of these events, they continue to occur and can result in significant morbidity for the patient and malpractice lawsuits for the surgeon. In thoracic spine, numerous risk factors influence the development of this misadventure. These include anatomical variations such as transitional vertebrae, rib variants, hemivertebra, and block/fused vertebrae as well as patient characteristics, such as tumors, infections, previous thoracic spine surgery, obesity, and osteoporosis. An extensive literature search of the PubMed database up to 2019 was completed on each of the anatomical entities and their influence on developing thoracic spine surgery at the wrong level, taking into consideration patient's individual factors. A reliable protocol and effective techniques were described to prevent this error. In addition, the surgeon should collaborate with radiologists, particularly in challenging cases. A thorough understanding of the surgical anatomy and its variants coupled with patients characteristic is crucial for maximal patient benefit and avoidance of thoracic spine surgery at the wrong level.
... Never events cirúrgicos incluem: realização do procedimento errado, em local errado, no lado incorreto, no paciente errado, retenção não intencional de um corpo estranho dentro de um paciente e morte durante a cirurgia ou no pós-operatório imediato de um paciente classificado como de baixo risco (estado físico 1, de acordo com a classificação da American Society of Anesthesiologists (ASA)) (Lindley et al. 2011). Em 2002, o American College of Surgeons publicou diretrizes para garantir que o procedimento correto fosse efetuado no paciente correto, em local correto. ...
... These protocols varies among different hospital and among surgeons. The 'Sign Through Your Initials' by the Canadian Orthopaedic Association 24) , the 'Sign Your Site' programme by American Orthopaedic Surgeons, the Sign, Mark and X-ray (SMax) programme by North American Spine Society 25) , and the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) 26) are among the commonly recognized protocols. ...
... In conventional methods, using pre-and/or intraoperative fluoroscopy is very common for the identification of the affected level. Many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery [6][7][8][9][10][11][12][13][14][15][16][17][18]. Spending more time for fluoroscopically identifying the spinal level may reduce the probability of wrong-level surgery; however, the amount of radiation exposure increases in the operating room. ...
... In general, predictive factors for the incorrect surgical site include the surgeon's experience and fatigue, unusual anatomy, thoracic level, and emergency condition [6,8,15,16,18]. To prevent wrong-site spine surgery, many alternative procedures and national protocols for localization of the level have been proposed in the literature [7,[9][10][11][12][13][14]17]. In traditional discectomy, one or two 20-gauge spinal needles were used to identify the localization of the correct surgical level preoperatively [9,11]. ...
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Background Although many reports are available on using a variety of instruments and techniques to prevent wrong-level spine surgery, the accurate localization of the correct spinal level remains problematic. At the same time, surgeons are also required to reduce radiation exposure to patients and operating room personnel. To solve these problems, we developed and used specially designed marking devices with a unique three-dimensional structure. PurposeTo evaluate the accuracy of our novel devices for localization of the spinal level to prevent wrong-level surgery and reduce the amount and time of radiation exposure during surgery. Study designThis was a retrospective cohort study. Methods In 8240 consecutive patients who underwent microendoscopic spine surgery between 1993 and 2012, the incidence of wrong-level surgery was studied. In addition, the amount of radiation exposure and total fluoroscopy time were measured in recent 100 consecutive patients using a digital dosimeter attached to the fluoroscope. ResultsEight (0.097 %) patients had undergone wrong-level surgery. The average radiation exposure was 0.26 mGy (range 0.10–1.15 mGy), and the average total fluoroscopy time was 3.1 s (range 1–7 s). Conclusions Our novel localization devices and technique for their use in spine surgery are reliable and accurate for identifying the target level and contributed to reductions in preoperative localization error and radiation exposure to patients and operating room personnel.
... Ambiguity in the labeling of spinal levels may arise when variation is present. Other studies have noted that wrong-level spinal surgery is the most frequent wrong-site procedure in orthopedics, and that anatomic variation is a risk factor [5][6][7][8][9]. However, in scoliosis, the fusion levels are based on global curve characteristics, including magnitude, stiffness, and sagittal profile, and no study has examined whether numerical variation has any effect on scoliosis surgery. ...
... Other studies have shown that anatomic variation can lead to the incorrect localization. One group reported that a wrong-level thoracic discectomy occurred in a patient who had both cervical ribs and absent T12 ribs, a variation that was not recognized until after surgery [7]. Another case report documented a discectomy performed at the wrong level in a patient with cauda equina syndrome who had a lumbarized S1 vertebra, unrecognized preoperatively [8]. ...
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Purpose Variation in rib numbering has been noted in adolescent idiopathic scoliosis (AIS), but its effect on the reporting of fusion levels has not been studied. We hypothesized that vertebral numbering variations can lead to differing documentation of fusion levels. Methods We examined the radiographs of 161 surgical AIS patients and 179 control patients without scoliosis. For AIS patients, the operative report of fusion levels was compared to conventional vertebral labeling from the first thoracic level and proceeding caudal. We defined normal counts as 12 thoracic (rib-bearing) and five lumbar (non-rib-bearing) vertebrae. We compared our counts with data from 181 anatomic specimens. Results Among AIS patients, 22 (14 %) had an abnormal number of ribs and 29 (18 %) had either abnormal rib or lumbar count. In 12/29 (41 %) patients, the operative report differed from conventional labeling by one level, versus 3/132 (2 %) patients with normal numbering (p < 0.001). However, there were no cases seen of wrong fusion levels based on curve pattern. Among controls, 11 % had abnormal rib count (p = 0.41) compared to the rate in AIS. Anatomic specimen data did not differ in abnormal rib count (p = 1.0) or thoracolumbar pattern (p = 0.59). Conclusions The rate of numerical variations in the thoracolumbar vertebrae of AIS patients is equivalent to that in the general population. When variations in rib count are present, differences in numbering levels can occur. In the treatment of scoliosis, no wrong fusion levels were noted. However, for both scoliosis patients and the general population, we suggest adherence to conventional labeling to enhance clarity.
... Never events cirúrgicos incluem: a realização do procedimento errado, em local errado, no lado incorreto, no paciente errado, a retenção não intencional de um corpo estranho dentro de um paciente e a morte durante a cirurgia ou no pós-operatório imediato de um paciente classificado como de baixo risco (estado físico 1 de acordo com a classificação da American Society of Anesthesiologists (ASA) (Lindley et al. 2011) . A comunicação é a base para a melhoria dos processos A comunicação interpessoal é condição ímpar para o sucesso de qualquer atividade humana e, com o objetivo de que seja efetiva, necessita da melhor troca de informações possível. ...
... As such, portable radiography must be used to verify the areas of lesion. In thoracic spine, it is safe to verify the level by counting the number of ribs on radiography, however, it requires attention when there is cervical rib or size of the 12th rib is small [16]. In the lumbar spine, attention is required in verifying the level if there is a transitional vertebra. ...
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Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as regarding patient safety. Despite the many wrong-site surgery prevention campaigns in spine care such as the operate through your initial program by the Canadian Orthopaedic Association, the sign your site program by the American Academy of Orthopedic Surgeon, the sign, mark and X-ray program by the North American Spine Society, and the Universal Protocol program by the Joint Commission, the incidence of wrong-site surgery has not decreased. To prevent wrong-site surgery in spine surgeries, the spine surgeons must put patient safety first, complying with the hospital policies regarding patient safety. In the operating rooms, the surgeons need to do their best to level the hierarchy, enabling all to speak up if any patient safety concerns are noted. Changing the operating room culture is the essential part of the patient safety concerning spine surgery.