Harvard Medical School, Boston, MA, USA.
DeGroote School of Medicine, McMaster University, Faculty of Health Sciences, Hamilton General Hospital, Hamilton, ON, Canada.
Acta Neurochir Suppl. 2023;130:179-184. doi: 10.1007/978-3-030-12887-6_21.
Wrong-level spine surgery, in which an operation is performed at a vertebral level different from the intended one, is a rare but serious complication with wide-ranging medical and legal effects. Although many protocols have been developed to prevent such a serious unfavorable event, the problem has not yet been eliminated. Research into the effectiveness of strategies to prevent wrong-level spine surgery is lacking. Herein, we describe a case of 44-year-old woman presented with neck pain and bilateral upper extremity weakness and numbness. Magnetic resonance imaging showed C5/6 and C6/7 disc herniations with spinal cord compression. The patient underwent anterior cervical discectomy and fusion; however, at the conclusion of the surgery, intraoperative radiographs showed that it was accomplished at C4/5 and C5/6-one level above the intended level. On the basis of this case and similar ones, a new protocol was developed that included implementation of a Spine Level Safety Checklist to document the reference point, the landmark, and the level of exposure that is marked on the intraoperative radiograph. Since implementation of this protocol, the incidence of wrong-level spine surgery at the senior author's institution has decreased from 4/7000 to 0/11,200. Adoption of this protocol by other centers is thus recommended to reduce the incidence of such complication.
手术部位错误，即手术在与预期不同的椎体水平进行，是一种罕见但严重的并发症，具有广泛的医疗和法律影响。尽管已经制定了许多方案来预防这种严重的不良事件，但问题尚未得到解决。关于预防脊柱手术部位错误策略的有效性的研究还很缺乏。在此，我们描述了一位 44 岁女性的病例，其表现为颈部疼痛和双侧上肢无力伴麻木。磁共振成像显示 C5/6 和 C6/7 椎间盘突出伴脊髓压迫。患者接受了前路颈椎间盘切除融合术；然而，在手术结束时，术中 X 光片显示手术完成于 C4/5 和 C5/6，即比预期水平高一个节段。基于这个病例和类似的病例，制定了一个新的方案，包括实施脊柱水平安全检查表，以记录参考点、标记和术中 X 光片上标记的暴露水平。自该方案实施以来，高级作者所在机构的手术部位错误的发生率已从 4/7000 降至 0/11,200。因此，建议其他中心采用该方案，以降低这种并发症的发生率。
