How to avoid wrong-level and wrong-side errors in lumbar microdiscectomy

Clinical article

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Object

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.

Methods

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.

Results

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.

Conclusions

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.

Abbreviations used in this paper: CT = computed tomography; DH = disc herniation; IRACE = intraoperative radiograph and confirming exclamation; ISO = International Organization for Standardization; JCAHO = Joint Commission on the Accreditation of Healthcare Organizations; RDH = recurring disc herniation; SMaX = Sign, Mark, and X-Ray.
Article Information

Contributor Notes

Address correspondence to: Claudio Irace, M.D., Department of Neurosurgery, Hospital Igea, Via Marcona 69, 20129 Milan, Italy. email: neurosurgery@casadicuraigea.it.

© AANS, except where prohibited by US copyright law.

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