25. Eur Spine J. Defensive medicine: a culprit in spiking healthcare costs. However, we did not observe any screw breakage in patients with a degenerative lumbar spine, and the absence of broken screws in this series is because arthrodesis in almost all patients occurred in situ. Careers. A neurologic deficit developed in one patient (0.9%) who had partial bilateral drop feet after reduction of L4L5 spondylolisthesis. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders, deformities, and trauma. The amount awarded was not significantly different across US regions (p = 0.9; Fig. Erwin WD, Dickson JH, Harrington PR: Clinical review of patients with broken Harrington rods. Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. And while the offending screw was removed the next day, Nyquist continued to experience right foot drop, along with lower back pain and sciatica, i.e. (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 18:23252326, 1993. 3. Epub 2014 Jun 13. Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison. 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. Nahed BV, Babu MA, Smith TR, Heary RF. Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. Clin Orthop 203:4553, 1986. Conversely, Nyquists foot drop did not resolve after the screw was removed, which begged the question of whether the foot drop was in fact caused by the misplaced screw. 11. This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. 2019;19(7):12211231. Dr. Abd-El-Barr is a consultant for Spineology. Arthrodesis was questionable in eight asymptomatic patients (7.1%). 2018;18(2):209215. Cotrel Y, Dubousset J, Guillaumat M: New universal instrumentation in spinal surgery. Submitting a contact form, sending a text message, making a phone call, or leaving a voicemail does not create an attorney-client relationship. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. The patient suffered permanent nerve damage as a result of the puncture. Spine 18:18621866, 1993. 22. This occurred on only one side and the correction achieved by the instrumentation was maintained. Three slender patients complained of soft tissue irritation and a bothersome prominence because of the screws bulky profile. 16,24,28 Simultaneously, the evolution of the surgical techniques has led to increased procedural safety. PLoS One. 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. Problems in the instrumented segments were considered those occurring from narrowing of the disc space greater than 3 mm, pseudarthrosis, and loss of reduction. 17. 24. 144 2 One of the first obstacles regarding . Spine 6:263267, 1981. Spine 18:11601172, 1993. Bydon M, Xu R, Amin AG, et al. Facebook Google Plus Youtube RSS Email. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. The third surgical procedure removed the pedicle screws but left the patient in an unfused state with an unstable spine. 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. Review of neurosurgery medical professional liability claims in the United States. Except for two patients with spinal metastatic disease, all other patients received an iliac crest autologous bone grafts. pedicle screw misplacement malpractice. South Med J 62:17, 1969. Many technological advances have been made over the past several decades in an effort to improve the accuracy of screw placement in spine surgery.3436 For example, 3D fluoroscopybased image guidance has been shown to decrease the pedicle breach rate in several studies compared to the rate with 2D fluoroscopic guidance or the freehand technique, particularly in deformity and revision surgeries.21,34,36,37 CT guidance or intraoperative confirmation has also been shown to further improve the accuracy of pedicle screw placement,3638 with reported accuracy rates of 89%100% reported in the literature, depending on the authors breach criteria.35 However, it is important to note that the use of this technology is often accompanied by a lower threshold for intraoperative screw revision, sometimes leading to higher rates of replaced screws.33 Arguably, these improved trajectories may avoid iatrogenic neurological deficits due to prolonged nerve root compression or even improve the stability of the construct;34,37 however, prospective studies of long-term outcomes and rates of revision surgery remain sparse in the literature. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim. A total of 47 (69.1%) cases resulted in a decision for the defendant and 21 (30.9%) for the plaintiff. Determining legal responsibility in otolaryngology: a review of 44 trials since 2008. Sarwahi V, Ayan S, Amaral T, Wendolowski S, Gecelter R, Lo Y, Thornhill B. Spine Deform. Pitfall: Unstable injuries. Two-dimensional (2D) fluoroscopy-guided percutaneous pedicle screw (PPS) placement is currently the most widely applied instrumentation for minimally invasive treatment of spinal injuries requiring stabilization. Materials and Methods Sixty . On April 6, a Union County, N.J., jury awarded a plaintiff $4.5 million over a botched spine surgery. It should be used by experienced and qualified surgeons who are familiar with the pitfalls associated with its use. Additional survey data have shown that 50% of physicians exhibit at least a temporary loss of self-esteem after a malpractice claim, and at least 25% experience depression.22 As stated above, the average neurosurgeon spends 27.2% of his or her entire career in an open malpractice claim,10 and each case can take an average of 5.1, 5.0, and 3.4 years for defendant verdicts, plaintiff rulings, and settlements, respectively.7,15 Likewise, neurosurgeons have a higher risk than practitioners in other specialties of being named in multiple malpractice suits given the particularly high-risk nature of the specialty.10 Even when found in favor of the defendant (surgeon), each case ultimately takes a substantial emotional and financial toll on the physician(s) involved. Mukherjee S, Pringle C, Crocker M. A nine-year review of medicolegal claims in neurosurgery. 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. Analysis and interpretation of data: Sankey, TT Than. Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary? However, the defendant doctor maintained that Nyquists foot drop was not caused by the misplaced screw. One hundred twelve patients were treated using the Cotrel-Dubousset pedicle screw fixation system for degenerative disease (57 patients), trauma (42 patients), infection (eight patients), and tumor (five patients) of the lumbar or thoracolumbar spine. 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. single homes for sale in lehigh valley, pa single homes for sale in lehigh valley, pa Home Realizacje i porady Bez kategorii single homes for sale in lehigh valley, pa * Phone/Fax: 30-2810-318361; E-mail: [emailprotected]. Pullout performance comparison of pedicle screws based on cement application and design parameters Tolga Tolunay, Cemile Bagl, Teyfik Demir, Mesut E Yaman, and Arslan K Arslan Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 2015 229: 11 , 786-793 Download Citation 34. One hundred twelve consecutive patients were entered into a retrospective study of instrumented thoracolumbar, lumbar, and lumbosacral spinal arthrodesis at our institution, between September 1994 and January 1999. Mason A, Paulsen R, Babuska JM, et al. A retrospective review of charts, XRs and low-dose CT scans of 127 patients who underwent spinal fusion with pedicle screws for spinal deformity was performed. Defensive medicine in U.S. spine neurosurgery. Cookie Policy. Nominal and inflation-adjusted award payouts were higher for trial verdicts than for settlement/arbitration, with a nominal average of $1,140,473 $841,683 versus $788,533 $306,186 awarded to the plaintiff, respectively (p = 0.30). 19. Acquisition of data: Sankey. While the majority of verdicts are found in favor of the defendant (surgeon), over 30% of cases in this study were found in favor of the plaintiff (patient), resulting in average inflation-adjusted payouts of over $1.2 million per claim over the past 25 years. Spine (Phila Pa 1976). A total of 2724 screws were placed in 127 patients. Legal liability in iatrogenic orbital injury. 2018;41(5):e615e620. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. While the majority of claims are found to lack merit, resulting in a verdict in favor of the defendant or case dismissal,7,1316 at least 37% are considered valid.26 Regardless, payouts to plaintiffs are often substantial, averaging in the hundreds of thousands to millions of dollars in both the US and Europe.10,11,14,17,20 Communication of errors and expectations, thorough documentation, and selection of appropriate patients and surgical indications have been shown to reduce the likelihood of a successful malpractice claim.13,16,27,28 In addition, attempts at tort reform in some states have helped limit the financial burden of medical malpractice payouts through methods such as capitation.16,20,22,26 However, efforts to limit malpractice claims in the first place are greatly needed. (A) Anteroposterior and (B) lateral radiographs taken 2 years after surgery show unilateral pseudarthrosis in a 55-year-old man with spinal stenosis. 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 . 15. Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis. Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study. Overall reported screw misplacement is low, but it does not reflect the potential impact on patient morbidity. Sethi MK, Obremskey WT, Natividad H, et al. Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. Am J Transl Res. Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo. 2022 Dec;31(12):3544-3550. doi: 10.1007/s00586-022-07427-0. 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. Don't jump in get legal help. Spine (Phila Pa 1976). Am J Otolaryngol. 33. 5. 2014;174(11):18671868. J Pediatr Orthop. Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. Spine 16(8 Suppl):S455458, 1991. Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. In six of these patients with injuries at the thoracolumbar area (four patients with bent screws and two patients with broken screws), the loss of correction ranged from 3 to 4.5 without change of anatomic reduction (Fig 1). Clin Orthop 203:126134, 1986. 2013;34(6):699705. The patient had subsequent coronal imbalance and degeneration of the upper disc. Balch CM, Oreskovich MR, Dyrbye LN, et al. Instead, the defense offered up an alternative explanation for Nyquists foot drop. Orthopedics. 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). 23. At the trials close, the plaintiffs attorney had asked the jury to return a $5.3 million verdict and had made a prior demand to settle the medical malpractice lawsuit for $1 million. 16. 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. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. 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. Despite this problem, the clinical result was excellent. First, this is a retrospective analysis of cases obtained from the web-based Westlaw Edge legal research database. Epstein NE. 10. 2017;31(3):287288. Stauffer RN, Coventry MB: Posterolateral lumbar-spine fusion: Analysis of the Mayo clinic series. Medical malpractice litigation has made a significant impact on spine surgery, with many spine surgeons avoiding complex cases or practicing other defensive medicine tactics in an effort to avoid being sued.5 Moreover, the majority of neurosurgeons spend more than 10% of their annual revenue on malpractice insurance,1,14 and the excessive financial risk of litigation is even leading some insurers to no longer offer coverage to spine surgeons.19 A 2011 study in the New England Journal of Medicine found that 19.1% of neurosurgeons are named as a defendant in a malpractice suit each year (highest of any specialty).12 Moreover, 88% of physicians in high-risk specialties, like neurosurgery, are involved in a lawsuit by age 45, increasing to a concerning 99% by 65 years of age.12 Such litigation places a substantial financial, temporal, and emotional burden on physicians in high-risk specialties, with studies showing that up to 72% of neurosurgeons1 admitted that their fear of litigation significantly influenced their practice,25 with many avoiding high-risk patients altogether.1 Similarly, Nahed et al. The accuracy of pedicle screw placement using intraoperative image guidance systems. J Spinal Disord Tech. 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. Guzek RH, Mitchell SL, Krakow AR, Harshavardhana NS, Sarkissian EJ, Flynn JM. 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. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. Mayo Clinic uses the latest robot-assisted technology when indicated to enhance surgical precision in these procedures. Quinnell RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. All the operations were done by one surgeon (PK). Bookshelf As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiffs spine. It was firstly introduced by Harrington and Tullos in 1969 and then in late 1980s developed by Roy Camille et al., Louis, and Steffe. None of these complications resulted in additional surgery or in a significant increase of morbidity. 26 They support that after a lengthy symptom-free period, segments next to a fused segment can break down and the segment next to the adjacent segment is almost as likely to break down as the adjacent segment. 8 spine surgeon insights, Lumbar spinal fusion cost in the 10 largest US cities, 2 MLB players undergo offseason spine surgeries, Salem Regional Medical Center adds spine surgeon, Here's how 6 spine surgeons prepare before a busy day, Total disc replacement cost in the 10 largest US cities, Study finds surgery more effective than conventional treatment for spinal stenosis, Dr. Rick Price completes his 50th AR spine case, Orthopedic surgeon among 2 convicted in $31M Medicare fraud scheme, SSM Health sues 2 resigning orthopedic surgeons, Surgeon leaves Rothman after 12 years to establish boutique spine practice, Jury awards $9.2M in botched spine surgery case, 'The numbers don't lie': Endoscopy to become more prominent among next generation of spine surgeons, Patient sues estate of late spine surgeon, 10 surgeons on the most controversial trends in spine, Connecticut orthopedic surgeon fined, reprimanded for operating on wrong hip, Ohio neurosurgeon facing wrongful death suit, Orthopedic surgeons at SSM Health resign, plan to start independent group, Wealthiest US orthopedic surgeon has a net worth of $1.8B, Orthopedic surgeons leaving SSM Health will partner with HOPCo for independent group, Wisconsin orthopedic surgeon sanctioned in patient's death, Healthgrades' best hospitals for spine surgery: 2023, How spine surgery competition is evolving by market: New York, Arizona, California and more, Indianapolis Colts linebacker has back surgery after consultation with Dr. Robert Watkins, Former Philadelphia Eagles player wins $43.5M verdict in knee injury case, California hospital cleared in counterfeit spine implant case, Georgia orthopedic clinic settles kickback suit, 22 hospitals ranked top 25 orthopedic hospitals 3+ years in a row, Stryker vs. Johnson & Johnson vs. Zimmer Biomet: How they compare in Q3, Neurosurgeon sentenced 5 years for accepting $3.3M in bribes, 12 surgeons who are leaving orthopedic groups for private practices, SSM Health canceling procedures as 11 orthopedic surgeons begin early departure, Aetna revises lumbar disc replacement policy, Indiana orthopedic surgeon settles Medicaid fraud allegations for $700K, 2 orthopedic hospitals facing Medicare readmission penalties, University of Toledo Medical Center suspends orthopedic chair, Here's what HOPCo's 1st Wisconsin partnership will look like, 2 Florida orthopedic providers merge to form 17-physician practice, 'This system is unsustainable': Why orthopedic surgeons do not feel fairly compensated, Orthopedic surgeon convicted for $31M staged fall scheme, Orthopedic surgeon buys $2M Chicago church, plans to convert to community hub, New Hampshire orthopedic surgeon arrested for alleged patient abuse, 8th Annual Becker's Health IT + Digital Health + RCM Annual Meeting. This patient recovered completely in 6 weeks. 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. Level of evidence: 1 Although this technique has advantages over open instrumentation, it also presents new challenges and specific complications. All Rights Reserved. Ultimately, no significant differences were seen in inflation-adjusted award information between plaintiff and defendant (Table 3). 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. 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. West et al 33 also reported a 29% complication rate for the first 50 patients and a 26% complication rate for the last 74 patients. FOIA Segal J. 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. Of note, while only 38.2% (n = 26) of cases in our study mentioned the use of intraoperative radiographic confirmation, only one of these cases reported that the misplaced screw had been caught prior to leaving the operating room, which had resulted in an inadvertent dural tear and L5 nerve root injury. 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. All case demographics are summarized in Table 1. Several limitations should be carefully considered when interpreting our results. The aim of this study is to evaluate the accuracy of pedicle screw insertion in spondylitis tuberculosis kyphosis correction using a freehand technique. Potential complications may include increased pain, infection, or mechanical . All the incidental dural tears were repaired immediately and produced no clinical sequelae. Deyo RA, Mirza SK, Martin BI. Spine 13:952953, 1988. Methods: There were 74 men and 38 women, with a mean age of 47 years (range, 1872 years).