Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England. 10. 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. 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. 2016;102(2):358362. Spine 18:23252326, 1993. National Library of Medicine The radiology results showed that the surgical screw placed at the right L4-5 area had breached the medial wall and was actually extending into the spinal canal. Spine (Phila Pa 1976). Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. Although pedicle screw fixation opened a new horizon of spinal surgery by providing rigid fixation of the spine, it is a technically demanding procedure with potential complications including medical complications, hardware and technical problems, and long-term changes of junctional motion segments. The cost of defensive medicine on 3 hospital medicine services, Defensive medicine in neurosurgery: the Canadian experience, Review of neurosurgery medical professional liability claims in the United States, A nine-year review of medicolegal claims in neurosurgery, Malpractice risk according to physician specialty, Neurosurgical experience with malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999 through 2003, Descriptive analysis of state and federal spine surgery malpractice litigation in the United States, Malpractice litigation following spine surgery, Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis, Malpractice claims in spine surgery in Germany: a 5-year analysis, On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim, Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England, Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort, It is easier to confuse a jury than convince a judge: the crisis in medical malpractice, Determining legal responsibility in otolaryngology: a review of 44 trials since 2008, Legal liability in iatrogenic orbital injury, Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study, Malpractice issues in neurological surgery. Facebook Google Plus Youtube RSS Email. The defendants explanation provided an explanation for why Nyquists foot drop did not resolve after the misplaced screw was removed and shed doubt on the plaintiffs theory of liability. Mason A, Paulsen R, Babuska JM, et al. Edmunds I, Cummine J, Fearnside M: Prevention of dislodgement of Cotrel-Dubousset rods from tulip screws. [] The accuracy for free-hand screw placement technique varies from 69% to 94%. As compared to cases in 19952009, those in 20102019 resulted in a significantly higher average nominal payout to plaintiffs ($776,439 $74,460 vs $1,506,000 $385,527, p = 0.028). Accessibility Fortunately, most of the complications were minor and transient. These numbers are in line with the current literature. In this example, the surgeon replaced the misplaced screw prior to leaving the operating room, which arguably played a significant role in the jury ruling in favor of the defendant (surgeon). They both had motor deficits from which 1 patient recovered completely. 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 In four of these patients, bent screws occurred at 8 to 10 months after surgery; in three patients, broken screw necks were seen 1 year after surgery and in two patients, tulip screw plug dislodgments were observed at 4 and 6 months postoperatively, respectively. ObjectThe goal of this study was to determine the incidence of screw misplacement and complications in a group of 102 patients who underwent transpedicle screw fixation in the lumbosacral spine with conventional open technique and intraoperative. Clin Orthop 115:130139, 1976. Ultimately, no significant differences were seen in inflation-adjusted award information between plaintiff and defendant (Table 3). 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. Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) Feb. 16, 2021 Accurate placement of pedicle screws is key to avoiding the potential complications of spinal fusion surgery and improving overall spinal fixation. Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison. Among the plaintiff-awarded cases, 13 (61.9%) were decided by jury trial, 7 (33.3%) by settlement, and 1 (4.8%) by arbitration. 20. 1. 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. This occurred on only one side and the correction achieved by the instrumentation was maintained. In addition, studies have shown that over 85% of malpractice claims are either dismissed or settled out of court,14 which likely results in a high degree of underreporting. However, this is the first study to evaluate the direct medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the US and presents important information that may support the routine use of intraoperative imaging confirmation (via 3D fluoroscopy or intraoperative CT) and/or navigated screw placement (either computer- or robot-assisted) as a potential method to decrease the risk of future litigation during spinal fusion procedures. PLoS One. Pedicle screw placement is a common procedure. 2002;27(22):24252430. 2022 Dec;31(12):3544-3550. doi: 10.1007/s00586-022-07427-0. Methods: Clipboard, Search History, and several other advanced features are temporarily unavailable. After the removal of duplicates, a total of 68 unique cases met our inclusion criteria and were included for analysis. Spine 18:11601172, 1993. reported that 69.3% of neurosurgeons who responded to their survey saw every patient as a potential lawsuit.1. Inaccurate pedicle screw placement is relatively common even when placement is performed under fluoroscopic control. One of the common means of doing so is to place a screw into each of two adjacent spinal bones (vertebrae), and then a rod between them. 2017 Mar;5(2):109-116. doi: 10.1016/j.jspd.2016.10.007. Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study. 2013;123(9):20992103. As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiffs spine. 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. It should be used by experienced and qualified surgeons who are familiar with the pitfalls associated with its use. 30. Zdeblick 38 also reported an overall arthrodesis rate of 65% in patients without instrumentation, 77% in patients with semirigid fixation, and 95% in patients with a rigid constrained screw-rod system. 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. Din RS, Yan SC, Cote DJ, et al. The aim of this study is to evaluate the accuracy of pedicle screw insertion in spondylitis tuberculosis kyphosis correction using a freehand technique. Laryngoscope. Pedicle screw instrumentation is widely used for the stabilization of the subaxial cervical, thoracic, and lumbar spine. 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. 32. 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. Study design: Bydon M, Xu R, Amin AG, Macki M, Kaloostian P, Sciubba DM, Wolinsky JP, Bydon A, Gokaslan ZL, Witham TF. Ann R Coll Surg Engl. 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. Intraoperative pedicle fractures requiring further points of fixation. Continued clinical experience with various pedicle screw implant systems has led to ongoing improvements in system design to minimize implant failure rates and to improve ease of system application. With increasing pedicle screw usage, the number of patients with misplaced screws will likely increase proportionally. Malpractice liability and defensive medicine: a national survey of neurosurgeons. The link was not copied. 6. Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. 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. 2014 Sep;21(3):320-8. doi: 10.3171/2014.5.SPINE13567. Spine J. The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. Taylor CL. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. Although the rate of the reported medical complications was high (36.5%), these did not significantly affect the final clinical outcome of the current patients. The majority of screws were misplaced in the lumbar spine for both plaintiff- and defendant-awarded cases (66.7% vs 57.4%, respectively, p = 0.564; Table 1). GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). Sub-analysis of adolescent idiopathic scoliotic patients showed no curve or patient characteristic that correlated with IMP or SAR. Quinnell RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. 0 attorneys agreed. $ = US$. 28. Conclusion: Personal consequences of malpractice lawsuits on American surgeons. Epub 2021 Aug 28. 2017;31(3):287288. reporting that the number of Medicare patients who underwent a complex lumbar spine fusion for spinal stenosis increased 15-fold, from 1.3 persons per 100,000 Medicare persons in 2002 to 19.9 in 2007.31 Similarly, a study by Rajaee et al. The amount awarded was not significantly different across US regions (p = 0.9; Fig. Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. The highly litigious environment within healthcare has resulted in a majority of physicians practicing defensive medicine,15 often leading to burnout6,7 and an exorbitant ethical and financial burden on medical and surgical care.7,8 In 2008, medical liability accounted for $55.6 billion, representing 2.4% of the United States (US) healthcare expenditures that year,5,7,9,10 and the pervasive practice of defensive medicine may cost up to $210 billion annually in the US.5 A similar trend has been observed in Europe.11, Neurosurgery is the specialty most frequently affected by lawsuits and the fear of litigation, both in the US and abroad,12 with spine surgery at the forefront.11,1317 As a result, spine surgeons are nearly three times more likely than nonspine surgeons to practice defensive medicine, defined as the avoidance of high-risk procedures and the provision of unnecessary services and assessments beyond what is clinically necessary in an effort to avoid litagation.5 The average time to judgment in a case is approximately 5.1, 5.0, and 3.4 years for defendant verdicts, plaintiff rulings, and settlements, respectively.7,15 As a result, physicians spend an average of 11% of their careers dealing with one or more open malpractice claims.18 Neurosurgeons are especially impacted, spending an average of 27.2% of their careers in an open lawsuit.10. Orthopedics. Hecht N, Kamphuis M, Czabanka M, et al. The patient had to undergo a subsequent surgery to remove the pedicles. Zucherman J, Hsu K, Picetti III G, et al: Clinical efficacy of spinal instrumentation in lumbar degenerative disc disease. Li HM, Zhang RJ, Shen CL. However, following the spinal fusion, Nyquist began to experience foot drop in her right foot. Phone/Fax: 30-2810-318361; E-mail: [emailprotected]. Spine Deform. Friedlander and Bradley will pay half of the $2.25 million. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? I won't be at the office but I will check my voice mail. Careers. Pedicle screw fixation is commonly used in spinal instrumentation surgeries to connect rods to vertebrae in order to correct spine alignment, stabilize vertebrae, and reach an arthrodesis. 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. 2012;7(6):e39237. J Spine Surg. Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. J Bone Joint Surg 73A:11791184, 1991. Sethi MK, Obremskey WT, Natividad H, et al. Spine 19:25842589, 1994. Objective: 5-7 Materials and Methods This is a retrospective study of kyphotic spondylitis tuberculosis (Stb) patients conducted at Fatmawati General Hospital, Jakarta, Indonesia, through the year 2020-2021. Spine 8:970981, 1996. 26. Materials and Methods Sixty . All the operations were done by one surgeon (PK). Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. The remaining eight patients, including two patients with spinal trauma, five patients with infection, and one patient with a tumor, had anterior and posterior procedures. Despite this problem, the clinical result was excellent. 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. The plaintiff will recover $2.25 million because of a high-low agreement the lawyers entered after closing arguments, the New Jersey Law Journal reports. 2012;21(suppl 2):S196S199. Nyquist had requested the defendants offer, which in retrospect was perhaps a poor decision in light of the Kane County jurys verdict. Unauthorized use of these marks is strictly prohibited. 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. 34. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. The initial search using the terms above returned 3654 cases. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Spine 6:263267, 1981. 2013;34(6):699705. Percentage of cases per US region (center). Overall reported screw misplacement is low, but it does not reflect the potential impact on patient morbidity. J Neurosurg Spine. Spine (Phila Pa 1976). Placement of the pedicle screws in the thoracolumbar and lumbar spine is a technically demanding procedure. Erwin WD, Dickson JH, Harrington PR: Clinical review of patients with broken Harrington rods. In 2 patients, misplacement of pedicle screws was recognized intraoperatively and all implants were removed. Dr. Abd-El-Barr is a consultant for Spineology. Lali Sekhon, Jocelyn Idema & more: 4 spine and neurosurgeons making headlines, Spinal cord stimulation trumps medication for pain reduction 7 takeaways, Dr. Khalid Kurtom on major trends in spinal cord injury surgery. Surg Neurol Int. It is easier to confuse a jury than convince a judge: the crisis in medical malpractice. 2009;10(1):3339. Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. The average followup was 35 months (range, 1851 months). Achieving proper lumbar lordosis, evaluating any preexisting scoliosis, and intraoperative assessment with AP radiographs could prevent balance problems. However, the defendant doctor maintained that Nyquists foot drop was not caused by the misplaced screw. Another possible cause was the high lateral torques to the entire frame that occurred during tightening of the tulip screw. Spine 16(8 Suppl):S422427, 1991. The total number of reoperations for MPS and patient clinical data were obtained from medical records at each hospital. Introduction. HHS Vulnerability Disclosure, Help Once the spine is exposed, the appropriate levels of fixation are confirmed with the image intensifier. An official website of the United States government. NCI CPTC Antibody Characterization Program. J Neurosurg Spine. Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. Whitecloud III TS, Butler JC, Cohen JL, Candelora PD: Complications with the variable spinal plating system. Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. 144 Thus, in the current study we aimed to describe this impact in the US, as well as to suggest a potential method for mitigating the problem. 14. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults, Spinal fusion in the United States: analysis of trends from 1998 to 2008, Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws, The accuracy of pedicle screw placement using intraoperative image guidance systems, 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, Pedicle screw placement accuracy using ultra-low radiation imaging with image enhancement versus conventional fluoroscopy in minimally invasive transforaminal lumbar interbody fusion: an internally randomized controlled trial, 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, Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO, 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, Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison, Verdict/Settlement Search and Inclusion/Exclusion Criteria, Plaintiff Claim and Index Surgery Information, Impact of Medical Malpractice on Neurosurgeon and Orthopedic Surgeon Careers, Financial Burden of Medical Malpractice Claims Related to Misplaced Pedicle and/or Lateral Mass Screws, Frequency of Misplaced Pedicle and Lateral Mass Screws in Spine Surgery, Strategies to Improve the Accuracy of Screw Placement in Spine Surgery, Top 25 Cited Gamma Knife Surgery Articles - Trigeminal Neuralgia, Top 25 Cited Gamma Knife Surgery Articles - Volume 111, https://doi.org/10.3171/2020.8.FOCUS20600, https://www.bls.gov/data/inflation_calculator.htm, Volume 49 (2020): Issue 5 (Nov 2020): Medicolegal issues in neurosurgery, Single vs multiple misplaced screw(s), no. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. Quraishi NA, Hammett TC, Todd DB, et al. Recently, robot-assisted pedicle screw implantation has been increasingly utilized at large-volume academic centers. In the remaining patients, the standard construct was three-segment fixation spanning four vertebrae and three discs, two above and one below the fractured vertebra, using six screws. In six patients (5.3%) with degenerative spine disease, the disc material had been removed. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the . Malpractice litigation following spine surgery. 2012 Feb 1;37(3):E188-94. Twenty-one patients (18.8%) had thoracolumbar injuries, and loss of immediate postoperative deformity correction ranged from 1.4 to 4.5. Furthermore, 25 patients (22.3%) reported persistent pain in the iliac crest (donor graft site) for several months, for which they were treated with repeated lidocaine injections and analgesics. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

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