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Balraj S. Jhawar, Demytra Mitsis, and Neil Duggal

the wrong level.” Before administering the survey, we were concerned that the event rate for ICSS would be low. To address this possibility, we increased the event horizon by asking participants also to report the number of ICSS events that occurred during the previous 5 years, as well as during the entire period they had been in independent practice. We recognized that these estimates would not be as reliable or as valid as our 1-year estimates. Incorrect-Site Surgery Event Rate To estimate the rate of ICSSs, we first determined the total number of

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Claudio Irace and Claudio Corona


When performing a single-level lumbar decompressive procedure, the first of all errors to avoid is operating at the wrong level or on the wrong side. In this report the authors describe their method of trying to minimize this potential risk.


A 3-step procedure—the IRACE (intraoperative radiograph and confirming exclamation) method—was designed and adopted for single-level lumbar decompressive surgeries. Before skin incision, a wire is placed in the spinous process and lateral fluoroscopy is performed. Subsequently and also before skin incision, the assistant nurse provides oral confirmation of the level and side. Additional fluoroscopic control is provided before starting the laminotomy. The clinical records of 818 consecutive patients who had undergone lumbar microdiscectomy as an initial operation between 2001 and 2005 were retrospectively reviewed. Surgical charts as well as clinical and neuroimaging follow-up data were analyzed.


No patient clinically and/or neuroradiologically demonstrated a level or side error. In 1 (0.12%) of 818 surgical procedures a wrong level was initially explored. The absence of frank disc herniation and the discrepancy with preoperative neuroimages led to fluoroscopic control in this case, and the correct level was then approached. No clinically apparent method-related complications were registered.


The problem of an incorrect level or side in lumbar surgery remains unresolved. The authors propose a useful and easily applied procedure to reduce such a risk. Larger studies comparing different methods of avoiding such errors will probably lead to the definition and wide adoption of a surgical behavior aiming to reach a near-zero error rate.

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Balraj S. Jhawar

T o T he R eadership : We thank Dr. Claudio Irace and colleagues for pointing out errors in the abstract of our paper, “Wrong-sided and wrong-level neurosurgery: a national survey” (J Neurosurg Spine 7:467–472, November, 2007). The correct rates of incorrect site surgery for lumbar and cervical discectomy are 12.8 and 7.6, respectively, per 10,000 cases, not 4.5 and 6.8 as stated in our abstract. The rate of incorrect site surgery for craniotomy should be 2.0 per 10,000 surgeries, not 2.2 as stated in our abstract. The data in the body of our paper

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Joshua M. Ammerman and Matthew D. Ammerman

Object Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons. Methods The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants

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Michael G. Fehlings

overall intraoperative complication incidence of 3.3% (23 of 700 procedures). The importance of tracking adverse events or errors is clear when one considers that most do not lead to complications and hence would not be flagged without a high degree of vigilance. In their paper in this issue of the Journal of Neurosurgery , Jhawar et al. emphasize the need for rigorous protocols to minimize perioperative error in neurosurgery. These authors used a survey of Canadian neurosurgeons to determine the incidence and possible determinants of incorrect-site surgery (ICSS) as