Surgery Knowing Where To Operate

Spine Marking And
Knowing Where To Operate

It might come as a surprise to readers of the Burton Report that wrong-level spine surgery, something which is a nightmare for patients as well as surgeons, is such a significant problem. Planning where to make an incision, as well as knowing where to operate is a most important determination.

In 2002 the Midwest Medical Insurance Company published a study involving thirteen physicians and eleven closed claims for which the total indemnity paid was $1.25 million because of wrong-level spine surgery. While there is no-fail safe mechanism for good surgical judgment a prudent consistency of approach will result in many fewer wrong-level surgeries.

While there is as yet no Global Positioning System in existence for guaranteeing correct anatomic localization for spine surgeons, the Burton Experience has shown that it is possible to markedly decrease the chance of error while also maintaining the highest level of patient safety. For routine operative procedures localization is important and can be accomplished by a number of different techniques.

Pre-operative spine marking-
Under direct x-ray control a metallic marker needle can be inserted against or into a dorsal process. The easiest approach is to deposit a visible dye into the skin as well as on the tip of a dorsal process. The illustration on the left shows a needle tip above the red dot on the L5 dorsal process. Dye is injected into both the skin as well as the tip of the dorsal process. The middle image shows the needle puncture site and residual dye. While this marking may be helpful in determining the skin incision dye deposited in this manner is notoriously unreliable for documenting anatomic level. The key is the dye (or metal marker) placed on the dorsal process and then correlating this with the scout x-ray. Dye placed on the L5 dorsal process is shown on the image to the right. ye can be seen in the skin and on the tip of a dorsal process.
Advantages:
    Relatively easy to perform.
    Done before surgery.
    General anesthesia not required.
Disadvantages:
    Not as reliable as intra-operative marking.

Operative observation and marking-
Under x-ray control metallic markers, such as needles, can be directly placed by the surgeon. In the image below a bent 18 gauge spinal needle has been placed in the disc interspace to identify it.
Advantages:
The most reliable marking procedure.
Disadvantages:
The risks of surgery increase with the length of time a patient is subjected to general anesthesia. Waiting for an x-ray technician and the developing of film may add significant time (and cost) to the surgical procedure.

Direct observation, such as that shown to the left, represents the highest level of accuracy of location. In the final analysis it is up to the surgeon to determine if they have found the expected pathology. If the exploration does not support this a reassessment of location is needed.

In patients with extensive spinal pathology, or previous surgery, there may extenuating circumstances where significant pathology is found and addressed at level other than the ones intended.