2021 Jul 1;41(Suppl 1):S80-S86. 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 It is indicated that screws medially misplaced at a distance greater than 2-mm, especially 4 mm, may be a cause of negative effects on the neural structure and should be removed during the early phase of the postoperative period, even among patients without postoperative neurological abnormalities. However, the misplacement of pedicle screws can lead to disastrous complications. The initial search using the terms above returned 3654 cases. 2012;41(2):6973. 2018;29(4):397406. Accuracy of pedicle screw insertion by AIRO intraoperative CT in complex spinal deformity assessed by a new classification based on technical complexity of screw insertion. $ = US$; MW = Midwest; NE = Northeast; SE = Southeast; SW = Southwest; W = West. 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. J Neurosurg Spine. 2020;162(6):13791387. The rate of reoperation for screw misplacement per screw was 0.17%. HHS Vulnerability Disclosure, Help Zdeblick TA: A prospective randomized study of lumbar fusion: Preliminary results. Another possible cause was the high lateral torques to the entire frame that occurred during tightening of the tulip screw. 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. The screws were needed to stabilize the spine and fix the fused vertebrae in place. Spine 18:983991, 1993. J Bone Joint Surg 62A:13021307, 1980. Steinmann JC, Herkowitz HN: Pseudarthrosis of the spine. To evaluate the accuracy of pedicle screw placement using a novel classification system to determine potentially significant screw misplacement. It should be used by experienced and qualified surgeons who are familiar with the pitfalls associated with its use. 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 instrumentation in the thoracolumbar and lumbar spine is a technically challenging procedure. Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients. What can spine surgeons do to improve patient care and avoid medical negligence suits? Recently, robot-assisted pedicle screw implantation has been increasingly utilized at large-volume academic centers. Mayo Clinic uses the latest robot-assisted technology when indicated to enhance surgical precision in these procedures. Disc space narrowing was the most common problem after instrumented arthrodesis and was observed in 27 patients (24.1%). Pedicle screw replacement in spinal surgery - The MDU These numbers are in line with the current literature. Accessibility Hecht N, Kamphuis M, Czabanka M, et al. 2. The patient suffered permanent nerve damage as a result of the puncture. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Spine (Phila Pa 1976). * 20. Nahed BV, Babu MA, Smith TR, Heary RF. 26. We serve the following localities: Cook County including Arlington Heights, Barrington, Berwyn Township, Chicago, Des Plaines, Glenview, Orland Park, Palos Park, Schaumburg, and Tinley Park; DuPage County including Downers Grove, Naperville, and Bolingbrook; Kane County including Aurora, Elgin and Geneva; Lake County including Waukegan; and Will County including Joliet. In situ spine arthrodesis permits load sharing by the vertebral bodies, preventing fatigue failure of the implant. It was firstly introduced by Harrington and Tullos in 1969 and then in late 1980s developed by Roy Camille et al., Louis, and Steffe. Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. 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 ]. 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. These complications may have resulted from powerful bending movement acting on the screw at its entry point to the bone. J Bone Joint Surg 54A:11951204, 1972. Screw Malposition: Are There Long-term Repercussions to Malposition of Pedicle Screws? Cerebrospinal fluid fistulas. 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. 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. Patient-specific 3D-printed surgical guides for pedicle screw insertion There were nine instrumentation failures at the thoracolumbar area (seven patients), lumbar area (one patient), and lumbosacral area (one patient). The https:// ensures that you are connecting to the 25. J Neurosurg. Similar to our findings, prior studies have shown that settlements result in lower payouts than cases that are ultimately taken to trial,7,14,15,30 with awards ranging from $125,000 to $9,000,000 compared to $134,000 to more than $38,000,000.7,15 Nevertheless, the true financial toll on spine surgery is largely unknown given that 85% of cases are dismissed or settled out of court, with undisclosed amounts.14 Likewise, substantial time is spent and costs, including legal and administrative, are incurred before judgment, as noted above. and 17.1% of the patients included had at least one screw misplaced. This decision must be made on a case-by-case basis at the surgeons and patients discretion after a thorough discussion of the associated risks and benefits of revision surgery. Re: malpositioned pedicle screw resulting in additional surgery and disability. PDF Intraoperative biomechanics of lumbar pedicle screw loosening following Pedicle screw insertion - AO Foundation The average followup was 35 months (range, 1851 months). Arthrodesis was questionable in eight asymptomatic patients (7.1%). Pedicle screw accuracy in thoracolumbar fractures- is routine Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants Irwin v. Alan Loren, M.D. Complications and Problems Related to Pedicle Screw Fixation - LWW 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. Unauthorized use of these marks is strictly prohibited. J Neurosurg Spine. Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo. 1 Although this technique has advantages over open instrumentation, it also presents new challenges and specific complications. 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. Rovit RL, Simon AS, Drew J, et al. All these problems were observed only just above the upper instrumentation level and all were observed in patients older than 55 years. 2013;123(9):20992103. Robotic-assisted pedicle screw placement fails to reduce overall 30. Determining legal responsibility in otolaryngology: a review of 44 trials since 2008. 3. Steffee AD, Brantigan JW: The variable screw placement spinal fixation system: Report of a prospective study of 250 patients enrolled in Food and Drug Administration clinical trials. 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. 4. Spine (Phila Pa 1976). Pedicle screw insertion in the thoracolumbar spine. J Bone Joint Surg 73A:11791184, 1991. 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. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. 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. Disclosures Dr. Karikari is a consultant for NuVasive, Globus, Johnson & Johnson, and DePuy and receives a spine fellowship fund from NuVasive. 2002;27(22):24252430. McLaughlin WM, Donnelley CA, Yu K, Gillinov SM, Tuason DA. 2011;306(10):1088. Spine 17:834837, 1992. An official website of the United States government. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. SECTION I SYMPOSIUM: Advances in Spine Surgery, Distribution of Spinal Disorders in 112 Patients, Classification of Complications in 64 patients. Malpractice issues in neurological surgery. 2012;89(10):7071. pedicle screw misplacement malpractice. Taylor CL. The intent is to provide relief from pain and nerve damage. The third patient, who had central spinal stenosis, was treated by decompression alone. 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. 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. Clin Orthop 203:717, 1986. 8600 Rockville Pike 27,30 Infected pseudarthrosis developed in one patient (0.9%) with an L4S1 arthrodesis, and the instrumentation was removed 18 months later resulting in a flat back syndrome. Quinnell RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. 18. (PDF) Lumbosacral pedicle screw placement using a fluoroscopic pedicle Despite these failures, solid spinal arthrodesis was obtained in all patients. Larson AN, Santos ER, Polly DW Jr, Ledonio CG, Sembrano JN, Mielke CH, Guidera KJ. When adjusted for inflation, these values increased to $1,330,201 $882,023 versus $970,832 $381,619, respectively (p = 0.32; Fig. Pedicle screws are used by spine surgeons as part of a fusion in which two adjacent bones in the spine are combined together as one. Plaintiff's expert was prepared to testify at trial that these complaints are characteristic of a malpositioned screw impinging upon a neural structure. Acquisition of data: Sankey. 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. 32. Lawsuit information regarding the plaintiffs age at the time of the malpractice claim, sex, postoperative complaint, indication for index surgery, defendant surgeon specialty (neurosurgery vs orthopedics), and delayed diagnosis or treatment, as well as case location by state and case year, was obtained. Achieving proper lumbar lordosis, evaluating any preexisting scoliosis, and intraoperative assessment with AP radiographs could prevent balance problems. Open lumbar pedicle screw technique - Operative Neurosurgery J Spinal Disord Tech. Nyquist had requested the defendants offer, which in retrospect was perhaps a poor decision in light of the Kane County jurys verdict. Nayar G, Blizzard DJ, Wang TY, et al. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the . Descriptive analysis of state and federal spine surgery malpractice litigation in the United States. Epstein NE. Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. 1). 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. In addition, the median time to judgment is substantial, particularly for defendant verdicts, spanning over 4.5 years from the time of surgery. Similarly, the highest inflation-adjusted amount awarded ($2,302,472) for pseudarthrosis was attributed to a medially breached pedicle screw during an L5S1 fusion that was determined to have caused the failed union and subsequent need for revision surgery. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. Spine 15:1114, 1990. Moreover, several cases stated that the surgeon used only the anteroposterior or the lateral view, but not both, and the plaintiffs counsel used this information in support of their claim. Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. Studdert DM, Mello MM, Sage WM, et al. Fortunately, most of the complications were minor and transient. Can Postoperative Radiographs Accurately Identify Screw Misplacements? Ann R Coll Surg Engl. Unilateral nonunion was seen in three patients (2.7%), associated with implant failure in one of the patients. 29. JAMA. 31. Clin Orthop 203:126134, 1986. Materials and Methods Sixty . Brodsky AE: Post-laminectomy and post-fusion stenosis of the lumbar spine. 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. In White AH, Rothman RH, Ray CD (eds). Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. Two patients had early postoperative postural headache that disappeared after removal of the misplaced screw.