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How often is the wrong level operated on??

jellyhalljjellyhall Posts: 4,372
edited 06/11/2012 - 8:46 AM in Back Surgery and Neck Surgery

I was wondering how common it is for the surgeon to get the wrong level during spine surgery.

I know that they x-ray to determine which is the correct level, so it shouldn't happen often.

My surgeon started to work on the level above my problem level that needed a fusion.
He realised his mistake and moved down to the correct level.
My surgical report said that he 'inadvertantly' cut a window into the laminar and then realised that it was not the area with the spondylolisthesis, so re-checked with an x-ray and then did the decompression (laminectomy, discectomy and facetectomy) and fusion on the correct level.

Has this happened to anyone else?

I hope that it won't cause me any problems in the future.



  • Did they not mark the area before? Hubby had his marked and cosigned by attendant. I know that people make mistakes but this is a spine they are operating on- mistakes are unacceptable. At least you have the documentation and they did not cover up.
  • I was wondering how often this happens but is not in the report? I know the surgical report doesn't include every little thing but I am amazed at what is often left out.

    My dad had heart surgery a few years back. They cut the mammory artery by accident (doctor later admitted it to him) but it was not in the report. There must have been one heck of a mess when that happened yet it was never mentioned.

    Only a surgical nurse could answer this one.

  • Jellyhall,

    Did you talk with your surgeon about this report? I too would be direct and ask about "affects" of his mistake - e.g. will I have problems later, and if so, who pays? Like Jim said, for me on mine, they marked me with purple marker! Did your surgeon even tell you, and the only way you found out was due to the report? Humm...that could be scary!!

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • Hi Jelly

    The brother of a friend had the wrong level operated on but didn't know it until he was home and the surgeon knocked on his door to apologise. He had to go back into hospital for the correct surgery, and he's fine now. That was a couple of years ago.

    I hope you won't have any problems in the future and can only recommend that you continue with your core strengthening exercises so that if there is a weakness in the laminar, the muscles will hold you together.


    XLIF L2-4 20.8.15
    ALIF L4/5 2009
    Laminectomy/discectomy L4/5 2008
  • We must all start to look and sound the same after awhile. My NS frequently asks about my specific symptoms. Unfortunately, he has me confused with someone else and so he is mentioning symptoms that I don't have. It's a little unsettling when we are having a discussion about treatment options and in his mind he is thinking about different symptoms.

    I know that this is not as bad as having the wrong procedure done. I will say that prior to all three surgeries, three or four different people asked me what was being done, where it was being done, and then the doctor noted it in marker on my back.

    I would be pretty upset if they did the wrong level. That's grounds for a malpractice suit (not that I condone it, but if there are new and lasting pain issues, it is clearly justifiable).
  • Thanks for the comments everyone. :-)

    I feel like my surgery has been successful, as the awful sciatica I had before surgery is almost gone. Occassional twinges and pains still, but I am only 4 1/2 months out. Everyone tells me that I am doing amazingly well for after fusion surgery.
    The recovery has been much easier than I was anticipating, so I am pleased with that. :-)

    I suppose my only worry is that if I need the higher level worked on at some point, (I already had a bulging and degenerated disc there) that there would be scar tissue to deal with, from the cutting into the bone that has already been done.

    Before my surgery, I placed myself into God's hands, so I am trusting Him that all will be ok. :D

    I did find, on one website, that operating on the wrong level can be a complication of surgery, but it is generally not mentioned. I would imagine, with all the checks that are made, it doesn't happen very often.

    My surgeon did come and talk to me before my surgery and went over my symptoms, but he didn't mark me up in any way. I was his first surgery of the day, because I was the major surgery.

  • the ward sister (he was a man) came to ask loads of questions. He asked ME which levels I was to be operated on (to ensure that I knew what I was there for). He also explained that because I was having L5-S1 and L4-L5 done, it was a very easy procedure because the surgeon could start at L5-S1. He explained that this was a very easily recognised disc/vertebrae. However, if I was being operated on any of the levels above, i.e. L4-L5, L3-L4 etc., they ALL looked identical. He also explained that some people's backs, whilst appearing to look similar, could be out of alignment from the norm, vertebraes could be smaller or larger than others and therefore, where the operation should occur it can be shifted up or down somewhat. It made perfect sense to me at the time!

    I was surprised by this, but because he was so thorough, I presume mistakes could be made. I was lucky I suppose that my surgery started with a disc that couldn't be confused with another, and so the one above was done afterwards. I don't know.

    Mistakes do happen - I thought that's why they had all the images available beforehand so they could be more precise about these things?
    2 x Microdiscectomy 2005 / PLIFusion 2-level 2010 / revision surgery 2011 / NEVRO Senza spinal cord stimulator implanted February 2013. I WILL NOT GIVE IN / UP !!
  • My surgeon didn't tell me. The day after surgery he told me that all went fine, and repeated that each time he saw me in hospital.
    There were things that the nurses and physio said that made me think that things weren't quite as was planned. They told me that my incision was longer than usual for this surgery, and that he had worked on another level. They kept telling me that I had had a bigger surgery than was planned.

    In my follow up appointments I asked about him working on another level and he said that things were much worse than he expected and he had to remove more bone than he had planned.

    He didn't give much information so I requested a copy of the surgery report from my GP.

    I was shocked to read it!
    It seemed clear to me that he had 'inadvertantly'(word used in the report) opened up the wrong level, rechecked by x-ray, and then decompressed and fused L4/L5. It did say that he had done a discectomy, laminectomy and wide undercutting of the facets, so lots of bone removal.
    No mention of the blood transfusion that I had.

    When I next saw the surgeon, I asked about his mistake. He said he hadn't made a mistake, that things were worse than he had anticipated, and he needed to remove more bone than he had planned.
    He also asked why I had requested a copy of the surgery report. I told him I was interested to read it!

    I have spoken to my GP, and she agrees that 'inadvertantly' means that he didn't mean to go in at that level.

    I accept that mistakes can easily be made, (especially when there are surgical cloths, and he is only looking a a bit of the back) but wish he had been up front with me, especially when I asked him about it.

    I had a theory that a 'dimple' in my back at the level above the spondylolisthesis caused him to think that was where the slip was. Perhaps he felt confident that he knew where he had to work.

    I have a copy of the x-rays taken during the surgery, and by the times on each picture, wonder if he even x-rayed to locate the correct level.
    There are just seconds between the first x-ray to locate where to make the incision, and the second picture to check because it was the wrong level. Not enough time to make the incision, cut a window into the laminar and realise the mistake and take another x-ray to recheck the level. There is also a very light area on the first x-ray that I believe is where bone has been removed.

    I don't intend to follow this up, as I accept that mistakes can be made.
    I would have loved to be a fly on the wall during the surgery. (Except that would have been unhygienic!! :O

    The reason for my post was to find out if it happens very often. I have read of one other person that has experienced this (lizzyboo). Actually reading that story is what made me wonder how frequently this occurs. Hence my post.

  • I don't know what to say. I am gobsmacked by this news. You must be very confused at this time and wanting more answers.

    My son's surgeon came in a put a mark on his back when he was being prepped for surgery. I thought that was the norm now.

    I think you must be able to get someone to look over it and maybe get copies of your x-rays/MRIs from before and after, if you don't have those already, just to find out what was done.

    Things do happen in surgery but mistakes like that are unacceptable and this doctor should probably be looked at to see if he is qualified enough to do this kind of surgery.

    I would think you could probably go online and fill in a complaint form to the NHS Trust in your area.

    Sorry I can't think of more to say but know that I'm sending you strength and gentle hugs. Try to just heal but I would still get the proof you need.

    P x
  • dilaurodilauro ConnecticutPosts: 9,878
    It is always tragic when it happens to you or someone you love, but mistakes are made. Medical people are just as human as any of us.

    Though, you do hope that they take all the proper precautions and pre-work to make sure that they operate on the correct area. Its not a lot to do, but it can make a huge difference.

    As it has been mentioned here, many doctors mark the area that needs to be operated prior to going into the surgical area. That helps.

    But think about this for a second. I know a true story of a person going in for GI surgery and the doctor did mark the areas and reviewed the X-Rays, Scans, etc all before going into surgery. So, there shouldn't be any reason for a mistake.

    Guess again, the doctor was handed the wrong charts!
    I know from my surgical experiences, the nurses, the associates, etc all check your wrist bracelet to make sure you are the right person, ask you what surgery you are about to have, etc.
    But I can not remember a time when a doctor asked me those same questions.
    So, here is a doctor going under the assumption that the charts handed to him by the associates and admin were for the person to be operated on.
    Bad thing, total different GI type of surgery!

    There are many ways something can go wrong like this. The best prevention is proper pre-work and thorough checking.

    How often does this happen?
    How often does it get reported?
    How often does the patient even now??
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com

  • Hi Ron,

    All the nurses and the anaesthetist did ask me who I was, date of birth and what surgery I was going to have. The surgeon also checked. I think he just assumed that he was going in at L4/L5, but he was one level higher.

    I would never have known if I hadn't seen the surgery report! Until that point, I just thought that I'd had a decompression at that level in addition to the L4/L5.

    If I was still in awful pain and not recovering well, it would be much harder to accept the mistake, but as I am so pleased with my recovery, I can accept that it was just an accident.

  • I had all the usual questions - date of birth, surgery, level, etc. My surgeon told me the incision would be about 1-2 inches. Well I get home and my husband measures it - 6-7 inches!! When I asked the doctor he changed the subject so I got no answer.

    I'm hoping to get some more info when I see another neurologist for my eye problems. Seems to me that someone made a big boo-boo and everyone is covering up.

    Spine surgeons are a very tight knit group. I've been told by a lawyer that they will not testify against each other - no matter what. I do accept that mistakes can happen. I am just very upset that one lies and another will swear to it.
  • Sorry to hear about the shocking news you got.
    Granted we are all human, But i sure hope that there are no negetive effects from this later down the road.
    i would make a couple copies of that report and make sure they are some place secure, just in case you need to bring them out at a later date.

    my neuro is sending me in for a CT Scan, due to me having issues with pain. i see my doctor every 4 weeks, any my pain is better since surgery, but the same level of pain i had after surgery, i still have so he is concerned about that.
    i go for a scan tomorrow, and he originally wanted me to wait til mid-september, when i will be 6 months post-op. then i go back to doctor in 3 weeks and will find out hopefully whats going on in there.

    sorry didnt mean to hijack your thread. hope every thing goes well for you
    take care and best wishes.
  • dilaurodilauro ConnecticutPosts: 9,878
    All doctors, spine specialists, etc are not like that.
    Only ones that have something to hide.
    I know of surgeons who would do anything for their patient and have no worries about what the other
    'surgeon-brothers' may do or say
    Ron DiLauro Spine-Health System Administrator
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com

  • Good luck with your scan tomorrow. Do you know why you are having a CT scan instead of an MRI scan?
    Anyway, I wish you well and hope that the news in 3 weeks will be good news. :-)

    My back is doing very well. :-)
    It is just my knees and neck that are causing problems now!
  • In the US...the operating room staff/surgeon is required by the JCAHO (a governing body), to take a time out once the patient and staff is in the room. We open the chart to the surgery consent and look at the patients armband. We agree that we are operating on the correct patient/birth date, and the correct procedure in the correct position. To me, it was the most important part of each case.


  • lol, nope dont know why the CT Scan and not MRI, from what i read online it appears to me that the ct scan is like a xray but its in alot more detail.
    when i get up in morning the pain level is high, i take my meds and they control my pain, but as the day goes on by 5 oclock, the meds cant control the pain anymore.

    told doctor can only sit for 1/2 hour then the pain goes all the way down my left leg.
    i can stand for 1/2 hour then the pain goes all the way down right leg.
    and the pain is always in my back at some degree.

    doctor put in the order yesterday for the scan, and they called me today got it set up for tomorrow, right after therapy.
    so just wait and see if something is goin on, or if this is what i live with.

    take care.
  • yup when i had my surgery i was asked by at least 6 different people my personel info. and they checked my wristband
    same when my daughter had her surgery someone was constantly asking who you are and checking the wristband

    it's just a little disheartning when mistakes like that are made, and it makes people start to wonder if and what else can be done to prevent that from happening.

    take care.
  • Haven't talked with you in a long time, I've been in hibernation over the pain/lack of fusion...sorry that you are having so much pain. I so hope that the CT scan will give you an idea of what is going on...much luck tomorrow.

    Yes, the medical field is constantly trying to find better ways to keep mistakes from happening.

  • SpineAZSpineAZ WiscPosts: 1,084
    Believe it or not, although our spines are generally the same in terms of how many vertebrae, when you open the spine it's not as if at first glance a surgeon can tell, for example, L3 from L2. So I respect the fact that he "stepped back" right after the start and did a re-check.

    In addition, it doesn't seem to be something that would likley cause future problems as, from what you said, he barely started and noticed something wasn't right. But only your surgeon can address that

    During my first lumbar fusion the surgeon nicked the dura mater and 8 weeks later I had a dural tear with spinal fluid leak. Everyone told me to be upset and sue, but I told them that based on what the possible complications can be, and since he took responsibility, I accepted the risk of the surgery and what could possibly happen. I did end up back in the hospital for a few days but since my insurance covered it, I had no real loss expect a little extra pain during the tap to insert a spinal catheter. The tear healed itself once they temporarily re-routed the spinal fluid.

    If there is no permanent damage or severe effect then to me it's one of the risks of undergoing spine surgery.
    2 ACDFs, 2 PCDF, 3 LIFs; Rt TKR; Rt thumb fusion ; Lt thumb arthroplasty; Ehlers Danlos 
  • I'm impressed with how you are dealing with this! That is a big credit to you and your character Jellyhall! I was going to mention Lizzyboo's post, but I figured (correctly it seems) that you would find the posts.

    I still think it sucks that the surgeon didn't have the balls to tell you right out. You're right, mistakes happen everyday, but most would own up to it, especially when the proof is in hand! By the tone, your surgeon seemed a bit mad that you got the reports? Hummm...

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • He wouldn't admit that he had made a mistake.

    He said the extra bone removal was due to the stenosis being very severe and much worse than he had anticiptated. I think that at the L4/L5 level, that was the case.

    However the surgery report said that he had 'inadvertantly' cut a fenestration (window) into the laminar at L3/L4, and found no stenosis or spondylolisthesis. That is what told him that he was at the incorrect level, because the MRI showed severe stenosis caused by the Grade 2 spondylolisthesis and the disc being pushed back into the spinal canal.
    That is when he checked the level, and realised that he needed to move down a level.
    Then he created another window in that laminar and found very severe stenosis and the slipped vertebra, so he continued by removing the laminar and part of the facets along with the disc.

    I expect after our chat, once I left the room, he re-read the surgery report and realised that it was pretty obvious that he HAD made a mistake. I'm sure that he is not used to being in that situation. He is a very experienced surgeon and known for being very good and creating very tidy incisions. You can see on my incision where he had to lengthen it. I think, all in all, what with the need for a transfusion, the incision not closing properly and then getting an infection, my surgery is not one of his proudest moments!

    In our area, there is a real shortage of spinal surgeons, so if I need surgery on my neck, I will be asking how he will ensure that he gets the correct level!!! Hopefully, it won't come to that.

    I have accepted that this happened and was an accident. It was lizzyboo's post that made me wonder how often it happens. (When I first learnt about it, I did have a while of being angry! - I have calmed down now :-))

  • Jellyhall~I am so sorry this has happened! I pray that there will be no further difficulty! How are your knees? Hopefully the swelling and pain is subsiding!

    Jim, so sorry to hear your pain levels are still so high! good luck on your CTscan and please let us know how you are doing!

    Lisa, how are you? I hope things are going in the right direction!

    Hope everyone has a good weekend!
  • Jelly,

    I guess as I read more and more on the 'backie' side of the house, I can understand as well how such things can happen. I was on track for L2/3/4 fusion until Neuropathy came into the picture! I guess if I go into such a procedure realizing this can happen, I too 'would' understand - hopefully I won't have this happen, but at least my brain knows it can. :)

    Being mad for a while, I get that. I'm still impressed at how you came to terms with it and your doctor. Hopefully one day soon he will "come clean" with you. Pride is a powerful emotion! *HUG*

    PCTF C4 - T2, Laminectomies C5, C6 & C7. Severe Palsy left arm/hand.
  • I recently had a 4 level posterior cervical fusion with hardware. No mistakes on the surgery, but they sure did on my meds. I was on 80mg of Oxycontin per day plus 5mg Oxycodone IR before the surgery. Hospital staff incorrectly entered I was only taking 5mg Oxycondone IR prior to surgery. After this big of a surgery they were only giving me two 5mg Oxycodone every 6 hours. For two days I was awake and hurting so bad I could hardly draw a breath in. I kept telling them but they just kept saying that should be enough. On the third day one of the PA's came in to investigate why I wasn't doing better. She realized the mistake and they changed my meds. I was ready to go home later that day doing great. My point is, it was the worst two days of my life and helped me understand that a 9 or 10 pain level is something I didn't truly understand before. At that level you are unable to do anything for yourself except exist.

    So the hospital made a mistake and it cost me two days of intense pain. I actually (I know this sounds stupid) am glad it happened. It has opened my eyes to how bad I "might" be; and therefore thankful for how well I'm doing. Yes it did irritate me they made the mistake, but the silver lining of this mistake is a new appreciation for the blessings of how well I actually am and where I could be.

    And the surgeon and his staff both apologized, even though it was hospital staff mistakes.
  • They are supposed to go over this with you right before the surgery, ask you about it, and write it on your skin. I had a fight with my physician's assistant right before my micro-d. She said, let's see, we're doing L4 today, right? I said - NO, we're doing L5. WHAT? No, no, it's L4 for sure. I said, "You're not wheeling me in there till you call someone and confirm it's L5. I am NOT leaving here with the pain I have now." Sure enough, she called and found out it was supposed to be L5. Didn't even apologize to me. Harumph. Well, that's only one of the reasons I didn't go back to that office for my fusion.
    3 level spinal fusion, L3/4, L4/5, L5/S1, November 2008. Stiff, but I can walk.

  • No swelling on my knees - just pain, collapsing and lots of noise.
    The supports do seem to be helping. I only wear them while I am exercising, but it means that I have much less pain. I have been told to stop some of the exercises.

    I feel like I am falling apart!

  • I appreciate all your answers.
    The fact that no-one else has said they had the wrong level operated on, confirms what I thought, that it is quite rare.

    My surgeon did check with me before surgery, and knew which level he was scheduled to work on.

    My guess is that the 'dimple' at the level above the slipped vertebra misled him to think that is where the slip was. I believe that when a spondylolisthesis causes a dimple, that it is usually at the same level as the slip. (If that makes sense) I bet he will be much more careful in future!
  • Boy do I understand the feeling of "falling apart!"
    There is nothing like healing from a fusion and having other issues with other body parts to cause those feelings! I was laughing and telling a friend that this is enough to cause an immediate midlife crisis! :) LOL

    Maybe we should go buy bright red sports cars and lepoard print stretch pants! And borrow Jim's bright red heels!

    Hang in there! Maybe wear your support braces when you are active like walking, shopping, vacationing, etc!

    I still can't do lunges without my knees swelling and I can't stand lunges, so it works out! :) Ha!

    Miss you! <3
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