pedicle screw misplacement malpractice

A total of 69 patients (mean age, 67.416 . 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. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders, deformities, and trauma. 2018;28(2):186193. 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. Patient safety: disclosure of medical errors and risk mitigation, Neurosurgical practice liability: relative risk by procedure type. Despite these failures, solid spinal arthrodesis was obtained in all patients. 2006;65(4):416421. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. Analysis and interpretation of data: Sankey, TT Than. Harrington PR, Tullos HS: Reduction of severe spondylolisthesis in children. However, this difference was no longer significant when adjusted for inflation ($1,016,000 $90,875 vs $1,630,000 $422,405, p = 0.09). Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. Spine (Phila Pa 1976). Zdeblick TA: A prospective randomized study of lumbar fusion: Preliminary results. 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. Copyright 1944-2023 American Association of Neurological Surgeons, Copy this link, or click below to email it to a friend. Twenty-one patients (18.8%) had thoracolumbar injuries, and loss of immediate postoperative deformity correction ranged from 1.4 to 4.5. Procedural errors led to combined payouts totaling $124,943,933 in neurosurgery claims between 2003 and 2012 in a study looking at data from the Physician Insurers Association of America Data Sharing Project.10 However, our study is the first to report the direct medicolegal impact of screw misplacement on US spine surgery, with 30.9% of judgments/settlements in favor of the plaintiff, resulting in average payouts of $1,204,422 $753,832 per claim. Copyright 2023 Becker's Healthcare. Results: A total of 2724 screws were placed in 127 patients. Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. 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). Routine CT scans were taken in all patients. At the lumbosacral area, breakage of a divergent screw of a Chopin block occurred on only one side with no loss of correction. 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. A total of 47 (69.1%) cases resulted in a decision for the defendant and 21 (30.9%) for the plaintiff. Nayar G, Blizzard DJ, Wang TY, et al. PLoS One. Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). Instead, the defense offered up an alternative explanation for Nyquists foot drop. The rate of reoperation for screw misplacement per screw was 0.17%. GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). pedicle screw misplacement malpractice. Start; O firmie; Usugi; Serwis; Realizacje i porady; Kontakt 2013;123(9):20992103. None of these complications resulted in additional surgery or in a significant increase of morbidity. Review of neurosurgery medical professional liability claims in the United States. 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. They both had motor deficits from which 1 patient recovered completely. Crawford MJ, Esses SI: Indications for pedicle fixation: Results of NASS/SRS faculty questionnaire: North American Spine Society and Scoliosis Research Society. Malpractice issues in neurological surgery. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. 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. 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. $ = US$; MW = Midwest; NE = Northeast; SE = Southeast; SW = Southwest; W = West. 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. pedicle screws sagittal alignment spinal fusion surgical guides Spinal fusion is used to treat a range of conditions associated with spinal column such as intervertebral disc degeneration and scoliosis [ 1 ]. It should be used by experienced and qualified surgeons who are aware of the pitfalls associated with its use. 38. The third patient, who had central spinal stenosis, was treated by decompression alone. J Bone Joint Surg 54A:11951204, 1972. For more information, please refer to our Privacy Policy. Lehmann TR, LaRocca HS: Repeat lumbar surgery: A review of patients with failure from previous lumbar surgery treated with spinal canal exploration and lumbar spine fusion. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. Three slender patients complained of soft tissue irritation and a bothersome prominence because of the screws bulky profile. Spine 13:696706, 1988. Placement of the pedicle screws in the thoracolumbar and lumbar spine is a technically demanding procedure. FOIA The medicolegal landscape of spine surgery: how do surgeons fare? 31. 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. J Spine Surg. What can spine surgeons do to improve patient care and avoid medical negligence suits? A total of 2724 screws were placed in 127 patients. Dr. Goodwin has received grants from the Burroughs Wellcome Fund, North Carolina Spine Society, and Robert Wood Johnson Harold Amos Medical Faculty Development Program and the NIH/NINDS K12 NRCDP Physician Scientist Award. 3. Careers. 2012;37(1):6776. The last two patients had a T12L1 fracture-dislocation and a L4L5 spondylolytic spondylolisthesis at the site of plug dislodgments. Clinical Orthopaedics and Related Research, Get new journal Tables of Contents sent right to your email inbox, The Association of Bone and Joint Surgeons, Complications and Problems Related to Pedicle Screw Fixation of the Spine, Articles in Google Scholar by Pavlos Katonis, MD, Other articles in this journal by Pavlos Katonis, MD, Privacy Policy (Updated December 15, 2022). 2007;106(6):11081114. 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. 4). Surg Neurol Int. 13. Image intensification and the technique recommended by Weinstein et al 32 was used for screw placement in the lumbar vertebrae, whereas Chopin blocks (Medtronic Sofamor Danek) with two screws diverging bilaterally were used for sacral fixation. Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) Summary of background data: The patient had to undergo a subsequent surgery to remove the pedicles. PMC Arthrodesis was questionable in eight asymptomatic patients (7.1%). Rather, the defense demonstrated that although the misplaced screw had in fact irritated the L4 nerve root for the six days before it was removed, the related symptoms resolved with the screws removal. Patient safety: disclosure of medical errors and risk mitigation. 2,24,28,36. + 48 696 042 504. It is an effective procedure in that it provides an almost immediate stabilization of the spine [ 2-5 ]. Epub 2021 Aug 28. 4. doi: 10.1097/BRS.0b013e31822a2e0a. 2021 Nov;9(6):1541-1548. doi: 10.1007/s43390-021-00377-5. The site is secure. Spine (Phila Pa 1976). Spine 16(8 Suppl):S455458, 1991. Li HM, Zhang RJ, Shen CL. Insuring spinal neurosurgery. There were no observed cases of screw misplacement outside the pedicle on routine AP and lateral radiographs. Makhni MC, Park PJ, Jimenez J, et al. (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. Jena AB, Seabury S, Lakdawalla D, Chandra A. J Bone Joint Surg 61A:201207, 1979. 2018;43(14):984990. 39. The intent is to provide relief from pain and nerve damage. Complications were classified as general, hardware-related, problems associated with the instrumented segments, junctional level problems, and problems related with balance (Table 2). 5 Those authors recommend that particular care should be taken in inserting the washers without cross threading and ensuring that they are locked down tightly, with an adequate length of rod protruding beyond the screw. Personal consequences of malpractice lawsuits on American surgeons. Problems at the junctions of the instrumented spine were seen in five patients (4.5%). [] Computer-assisted computed tomography (CT) techniques have improved the overall accuracy for pedicle screw placement, and has reduced complication rates. 2018;29(4):397406. 19. All Rights Reserved. Copyright © 2023 Becker's Healthcare. Todd NV. Median screw misplacement rate was 10% in group A and 13% in group B. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. While reported to be one of the best legal research resources available and utilized in several previous studies,7,14,16,23,24 available court documents and clinical/operative details are highly variable and greatly limited among case files. However, only a few complications were related to a poor clinical outcome. $ = US$. I won't be at the office but I will check my voice mail. Except for the patient with an infected pseudarthrosis who had a flat back syndrome (sagittal imbalance) develop, coronal imbalance was observed in five patients (4.5%), and ranged from 7.5 to 12 (Fig 3). were excluded from analysis. The plaintiff received $2.4 million for pain and suffering and loss of enjoyment of life, $2 million for lost income and approximately $123,000 for medical expenses. This site needs JavaScript to work properly. 2018;83(5):9971006. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Unable to load your collection due to an error, Unable to load your delegates due to an error. 14. 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. 9. Lawsuit information regarding the plaintiffs age at the time of the malpractice claim, sex, postoperative complaint, indication for index surgery, defendant surgeon specialty (neurosurgery vs orthopedics), and delayed diagnosis or treatment, as well as case location by state and case year, was obtained. Over 40% of patients had screws with either some/major concern. Spine 16:576579, 1991. The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. Under this theory of liability, the plaintiff needed to not only establish that she had experienced foot drop, a fact that no one was disputing, but that it was caused by the defendants negligence. 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. Dr. Abd-El-Barr is a consultant for Spineology. J Pediatr Orthop. General complications were considered those developing during and after surgery that were not directly related to instrumentation. 8,24,25,32. doi: 10.1097/BPO.0000000000001828. Spinal fusion procedures are increasingly performed each year, with Deyo et al. SECTION I SYMPOSIUM: Advances in Spine Surgery, Distribution of Spinal Disorders in 112 Patients, Classification of Complications in 64 patients. ABSTRACT: Pedicle screw loosening has been implicated in recurrent back pain after lumbar spinal fusion, but the degree of loosening has not been systematically quantied in patients. Mayo Clinic uses the latest robot-assisted technology when indicated to enhance surgical precision in these procedures. 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. Notwithstanding these concessions, the MDU argued that misplacement of pedicle screw tracts was common in surgery of this kind, even in experienced and competent hands. Conception and design: Sankey, KD Than. Thu, May 27th, 2021. Defensive medicine in neurosurgery: the Canadian experience. West III JL, Bradford DS, Ogilvie JW: Complications of the variable screw pedicle screw fixation. This study has shown that percutaneous insertion of pedicle screws in the lumbar spine is a safe and reliable technique, and despite the low misplacement rate of only 6.6%, it should be kept in mind that the surgical procedure is technically demanding and should be performed only by experienced spine surgeons. Clin Orthop 203:4553, 1986. 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. Defensive medicine in U.S. spine neurosurgery. Pedicle screws have been used to treat spinal disorders, including those caused by spinal cancer, congenital anomalies, trauma, and chronic pain syndromes. Methods: Lumbar Spine Surgery. Each case was then carefully screened for relevance and sufficient data. Brodsky AE: Post-laminectomy and post-fusion stenosis of the lumbar spine. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. Neurosurgical experience with malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999 through 2003. Figure 1: Lower thoracic pedicles provide the firm purchase of the pedicle screw from a lateral starting point and 10-15 degrees convergent angle Surgical technique "Free Hand" pedicle screw placement [50] Our "Free Hand" technique is equivalent for lumbar and 22. 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). concluded that the robot-assisted technique was significantly more accurate than the traditional freehand technique.39 Despite the learning curve and initial cost of obtaining technologies such as 3D fluoroscopic devices, intraoperative CT, or robotic navigational systems, the routine use of these technologies for intraoperative imaging confirmation and potential revision of misplaced screws may help spine surgeons avoid inadvertent iatrogenic morbidity for their patients and potential litigation. 2018;18(2):209215. 5. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. 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. Malpractice litigation following spine surgery. Screws penetrating the anterior cortex and abutting vascular structures, particularly aortic abutment with left-sided screws, which can lead to erosion and pseudoaneurysms. J Spinal Disord Tech. Under the high-low agreement, Drs. This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. Thus, meaningful efforts to limit the rate of misplaced pedicle and lateral mass screws, such as the routine use of intraoperative imaging confirmation and/or computer- or robot-assisted navigation, should be carefully considered. Spine 16(8 Suppl):S422427, 1991. The instrumentation and bone graft were left in place in these patients (total infection rate, 2.7%). Two patients had early postoperative postural headache that disappeared after removal of the misplaced screw. Steinmann JC, Herkowitz HN: Pseudarthrosis of the spine. Previous biomechanical and clinical studies defining junctional segment problems are lacking and consist mainly of case reports. The most frequent primary injury listed for a lawsuit was nerve root injury, present in 81.0% (n = 17) and 74.5% (n = 35) of plaintiff- and defendant-awarded cases, respectively (p = 0.7). Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. Clin Orthop 203:717, 1986. official website and that any information you provide is encrypted Inaccurate pedicle screw placement is relatively common even when placement is performed under fluoroscopic control. However, the misplacement of pedicle screws can lead to disastrous complications. Preparation. Koktekir E, Ceylan D, Tatarli N, Karabagli H, Recber F, Akdemir G. Spine J. INCLUDE WHEN CITING DOI: 10.3171/2020.8.FOCUS20600. 12. Litigation resulted in average payouts of $1,204,422 $753,832 between 1995 and 2019, when adjusted for inflation. These risks can be minimized by the judicious use of instrumentation by experienced surgeons for specific indications as supported by the literature. 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. Spine arthrodesis was evaluated with plain AP and lateral radiographs taken 1 year after surgery. The third surgical procedure removed the pedicle screws but left the patient in an unfused state with an unstable spine. Forty-seven intraoperative and medical complications were observed in 41 patients (36.6%). The purpose of current study was to analyze the complications and problems during and after pedicle screw fixation for various spinal disorders and trauma. Johnston II CE, Ashman RB, Baird AM, Allard RN: Effect of spinal construct stiffness on early fusion mass incorporation: Experimental study. Disc space narrowing was the most common problem after instrumented arthrodesis and was observed in 27 patients (24.1%). Moffatt-Bruce SD, Ferdinand FD, Fann JI. J Neurosurg. Administrative/technical/material support: Mehta, Wang, KD Than. J Neurosurg Spine. Feb. 16, 2021 Accurate placement of pedicle screws is key to avoiding the potential complications of spinal fusion surgery and improving overall spinal fixation. Legal liability in iatrogenic orbital injury. Scarone P, Vincenzo G, Distefano D, et al. Pitfall: Unstable injuries. Spine 6:615619, 1981. Eur Spine J. Epstein NE. Despite this problem, the clinical result was excellent. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. Pedicle screw placement safety with the aid of patient-specific guides in a case series of patients with thoracic scoliosis. Phone/Fax: 30-2810-318361; E-mail: [emailprotected]. N Engl J Med. Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants Irwin v. Alan Loren, M.D. 8. Harrington and Tullos 11 first reported the technique of transpedicle screw fixation, and Roy-Camille et al 23 popularized the first practical method of pedicle screw fixation. J Neurosurg Spine. 18. Friedlander and Bradley will pay half of the $2.25 million. Rovit RL, Simon AS, Drew J, et al. Autor de la entrada Por ; Fecha de la entrada austin brown musician; matrix toners for bleached hair . your express consent. 1). Through the use of expert witness testimony, Mr. da Costa was able to prove to the jury that by misplacing the pedicle screw during the surgery, and failing to timely diagnose and correct the malpositioned screw, Defendants deviated from accepted standards of care. What can spine surgeons do to improve patient care and avoid medical negligence suits? 21. 2020;45(2):E111E119. Elsamadicy AA, Sergesketter AR, Frakes MD, Lad SP. 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. Am J Orthop. Malpractice risk according to physician specialty. A total of 2396 screws were placed accurately (87.96%). Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in Zaleski v Elmhurst Eye Surgery Center. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). In unstable injuries, the segments above and below the level of injury may have a different orientation of the pedicle trajectory due to . . Screw Malposition: Are There Long-term Repercussions to Malposition of Pedicle Screws? Hardware problems were those related to the physical change of metal and screw position. Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO CT scanner. Wolters Kluwer Health Mukherjee S, Pringle C, Crocker M. A nine-year review of medicolegal claims in neurosurgery. Subjects were 10,754 patients (73,777 pedicle screws) who underwent PSF at 11 hospitals over 15 years. 2014 Sep;21(3):320-8. doi: 10.3171/2014.5.SPINE13567. Epub 2014 Jun 13. Author links open overlay panel Mohamad Bydon a b 1, Dimitrios Mathios a b 1, Mohamed Macki a b, Rafael De la Garza-Ramos a b, Nafi Aygun c, Daniel M. Sciubba a, Timothy F. Witham a, Ziya L. Gokaslan a b, Ali Bydon a b, Jean-Paul Wolinksy a. 2019;19(7):12211231. 2017;42(3):177185. Cookie Policy. Intraoperative and postoperative complications were recorded by the authors and the results were evaluated by an independent observer. Cotrel Y, Dubousset J, Guillaumat M: New universal instrumentation in spinal surgery. 3,4,9,29,34 In addition, developments in surgical technique and implant design have decreased operative risk and implant-related complications. The remaining two patients had asymptomatic junctional problems develop after two- and three-segment fusions, at the third and fourth postoperative year, respectively. 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. Am J Otolaryngol. This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. Adjusted for age and preoperative Cobb angle, patients with a higher misplacement rate were more likely to have screws . Plaintiff award amounts were adjusted for inflation as of April 2020 using an online inflation calculator provided by the US Bureau of Labor Statistics (https://www.bls.gov/data/inflation_calculator.htm). Finally, considering the problems of balance, it seems that failure to properly evaluate any preexisting scoliosis was a main cause of this important complication. From the *Department of Orthopaedic Surgery, University of Crete Medical School, Heraklion, Greece; and the **First Department of Orthopaedics, University of Athens Medical School, Athens, Greece. Spine 19(20 Suppl):2279S2296, 1994. 11. Spine (Phila Pa 1976). 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). Epub 2014 Apr 4. 2021 Jul 1;41(Suppl 1):S80-S86. The contact form sends information by non-encrypted email, which is not secure. Whitecloud et al 35 reported an overall 45% rate of minor and major complications, with the rate of complications increasing to 63% in patients who had previous lumbar surgery. Ahmadi SA, Sadat H, Scheufler KM, et al. Schatlo B, Molliqaj G, Cuvinciuc V, et al. Problems of balance were coronal (scoliosis greater than 5 or trunk shift greater than 5 mm) as seen on the AP radiograph taken with the patient standing or sagittal (failure to obtain or maintain lumbar lordosis). Rajaee SS, Bae HW, Kanim LE, Delamarter RB. 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. 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. The accuracy of pedicle screw placement using intraoperative image guidance systems. J Am Coll Surg. The rod is held in place by "pedicle screws," which the surgeon must insert into the pedicles. * Spine 17:349355, 1992. Dr. Friedlander did not order a CT or MRI until January 2013, when the pedicle screw was found to be in the wrong location and a failed fusion was diagnosed, according to the suit. Studies have shown that the greatest proportion of malpractice claims in spine surgery are related to procedural error,10,11,14,16,17,19 often resulting in the highest payouts.11,20 For spine surgery, one common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass screws, which occurs in approximately 14%55% of cases using standard techniques and results in neurological injury and/or durotomy in approximately 1%8% of cases.21 Misplaced screws have the potential to cause severe and sometimes permanent neurological deficits, including spinal cord and/or nerve root injury,21 as well as to decrease the stability of the fusion construct, leading to delayed complications related to pseudarthrosis. Erwin WD, Dickson JH, Harrington PR: Clinical review of patients with broken Harrington rods. 2014;174(11):18671868. Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. Similarly, the highest inflation-adjusted amount awarded ($2,302,472) for pseudarthrosis was attributed to a medially breached pedicle screw during an L5S1 fusion that was determined to have caused the failed union and subsequent need for revision surgery. Several limitations should be carefully considered when interpreting our results. 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.

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