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Surgical error

Hi everyone, I am new to this forum. Back in October I had thoracic back surgery - discectomy, fasciotomy, laminectomy, that was supposed to occur at T8/T9. Unfortunately the surgeon made an error in level localization and did the surgery on the normal level above before she realized she was at the incorrect level. She then moved down to the correct level and performed the surgery. So basically I ended up with a two level procedure - T7/T8, T8/T9. I haven't had my first follow up visit so haven't had the opportunity to discuss this further with her, but my concern is long term stability. How many of you had a two level thoracic procedure who later on had to go back for fusion? Thank you.


  • jellyhalljjellyhall Posts: 4,373
    edited 11/14/2013 - 6:43 AM
    I am very sorry to hear of your error during your thoracic surgery. Thoracic surgery is hard enough without having an extra level added!

    How did you find out about the error?

    I haven't had thoracic surgery although I do have three problem thoracic discs, two of which are slightly compressing my cord.

    During my lumbar laminectomy and fusion done over 3 and 1/2 years ago, my surgeon started to operate on the wrong level. He then saw that there was no stenosis or spondylolisthesis at that level and so extended the incision and moved down and proceeded to to the correct surgery. Fortunately he had not got far before he realised his mistake. I became suspicious when the nurses and physiotherapists were telling me that my surgery had been more invasive than planned and that two levels had been involved. My surgeon never said anything about it and just said that all had gone fine.

    I got a copy of the surgery report from my GP and that stated that he had 'inadvertantly cut a fenestration into the lamina at L3/4, saw that there was no stenosis or spondylolisthesis, checked levels by x-ray and then moved down a level to L4/5.'

    I am not sure that we have any members that have had two thoracic levels worked on and then had to go back for a fusion, but there is a section on here for thoracic spine problems so I suggest that you take a look at that. There are certainly other members who have had thoracic fusions.


    Welcome to Spine Health :-)
  • dilaurodilauro ConnecticutPosts: 9,842
    edited 11/14/2013 - 7:08 AM
    surgeons operating at the wrong spot. Worst case I think I ever heard about was a hip was replaced on the wrong leg! (but still, hip replacements are done most of the time from the wear/tear from arthritis, you would think the surgeon could see if that was a healthy hip or not)

    I am not sure if it is because of teaching hospitals, but every time I have had surgery, spinal or joint,

    • The nurse would ask me to identify the surgery being done so we both knew
      The Anisthesa doctor would ask me the same questions
      The Pre-Op nurse would ask the same questions
      The Surgeon came in, asked the same questions, wrote on the area that will be worked on
    That leaves little for error, unless the surgeon 'forgets' about the previous check and balances. Same holds true for spinal surgery. What area? (Lumbar, cervical) Which discs? (Lx Cy), What type of surgery? (Fusion,scraping, etc)

    Maybe it is because that is done more at teaching hospitals, so that the interns , PAs and others participating or watching the surgery will know exactly what needs to get done.

    I do hope that since additional surgery was performed on you, that it will not impact your recovery time and the overall longer term outlook. How did you feel after the surgery? Since its still pretty new (since October) I guess you are still in the post surgical pain phase.

    If anything at your follow up, I would ask How did this happen? Not because of any legal problems you might want to bring up, but from a procedural view. Weren't there checks in place to avoid that type of error? I would hope that the surgeon would be honest and give you a straight answer
    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
  • jellyhalljjellyhall Posts: 4,373
    edited 11/14/2013 - 11:20 AM
    I tried to ask the same thing of my surgeon, but he wouldn't discuss it with me, even saying that he had intentionally operated on the higher level because things were worse than he thought and he had to remove more bone. Then he realised that I had a copy of the surgery report. That made it pretty clear that he had 'inadvertantly' started at the wrong level and then moved down to where the decompression and fusion was needed. He then wanted to know why I had got a copy of the surgery report. I just answered that I had wanted to see what had gone on. I didn't mention that the nurses and physiotherapist had said things that had caused me to be suspicious. That may have got them into trouble!

    I can accept that mistakes can be made but I wish he had been upfront with me about it. I had a theory as to why it had happened and wanted to see if my idea was correct but our discussion didn't get that far. I think he was trying to protect himself. I expect that some patients would have taken things further. My end result has helped me and that is the main thing.

    I would have loved to have been a fly on the wall in the operating room, except that would have made it unsterile!

  • dilaurodilauro ConnecticutPosts: 9,842
    Worse, you could have fallen into your wound!
    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
  • I hope you heal well and never run into any problems with this.
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • In pre op, the surgeon came in and had me turn over, at which point he proceeded to mark up my back, he said he was marking the level to be operated on for all to see. In the hall outside the OR three different staff members asked me my name, birthdate, what I was having, and where. I don't remember anything after that. I now understand this was part of their pre flight checklist.
    What I don't understand is how this happens when it is so simple to just take a quick pre incisional X ray to verify where the surgeon wants to be. I know they did intraoperative X rays on me because I got the radiology bill before any others! Ironically, it appears to be the least expensive thing I will have to pay for, yet was probably one of the most important items in my procedure.
  • For my last 4 spine surgeries.... when my surgeon came in to do the "pre talk" he would have me sit up and he'd just stick a random blue x on my back and laugh about it... he said it was protocol but there was no way to indicate on my back where exactly he'd want to start, that he always started with an x-ray.... makes sense to me...
    33yo mom of two. My surgical history...preadolescence scoliosis, kyphosis, and a hot mess.... 5 spine surgeries and lots of items added I wasn't born with (titanium, peek, surgical steel). Guess cremation is out. TSA loves me.
  • I've had 5 right knee surgeries and they always marked my knee as a precaution. They didn't mark my back for my fusion, but multiple people asked me what I was having done, including my own surgeon, who also put a wristband on me with the details of the procedure he would be doing.
    10/28/13 - ALIF, PSF, decompression at L4/L5 and L5/S1
  • dilaurodilauro ConnecticutPosts: 9,842
    edited 11/14/2013 - 4:24 PM
    Shoulders and Hips Totally Replaced, both surgeons (1 for the Shoulders, 1 for the Hips) both
    had their surgical notes up on a wide screen , along with Xrays, MRIs, etc so that they could reference everything while
    they are performing the surgery.

    With the amount of data available and the newer more effective ones in displaying this, its almost hard to believe that a surgeon could perform the surgery on the wrong item/spot/space/etc

    If they take advantage of all of this, then there should never be a mistake.... Never....Hmmm thats a pretty strong word
    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
  • Protect yourself for the future and retain a malpractice attorney


  • I had thoracic microdiscectomy, lamenectomy and fusion using bone removed. This was according to my insurance authorization sent to me about a week after surgery. I have repeadedly asked for surgical report from surgeon. Have called his office numerous times and even called hospital administrators office. No report and my surgery was done May 24,2012. My NS who referred me to him never got report. My GP requested copy...never received. I continue to have problems with this level so NS once again requested last month. Hasnt heard a word. The only ones who received a report is State of NC disability who were deciding status of disability. I am going to try to go through my disability lawyer and see if he can get copy for me. I have a feeling there is a reason they dont want me to see and have not contacted me since My one and only post surgery visit with him 2 months after surgery. I was never even released from care after my surgery and still havent been. After reading all the above posts now I am curious as well as concerned :(

  • When I had my 4level cervical fusion they did not mark and mine was a teaching. They had 2 anatheseiologist but no markings. Strange T have

  • jellyhalljjellyhall Posts: 4,373
    edited 11/15/2013 - 2:24 AM
    They are supposed to do pre-surgery x-rays to get the level right!
    My surgeon didn't mark me up at all. I do think they asked my name, date of birth and probably what surgery I was having, but I don't remember.
    I was having a lumbar fusion of L4/5 due to a grade 2 spondylolisthesis.
    I had a 'dimple' in my back, but it was higher than the slipped vertebra.
    I think that when he saw the dimple he thought it was obvious that was where the slip was and so didn't bother to x-ray. He must have got a shock when he realised that it was the wrong level.
    I have a copy of the surgery x-rays taken. There is only about 30 seconds on the digital time between the first and second x-rays. Definately not enough time to make the incision and fenestration into the lamina, discover it was the wrong level and to move down a level and extend the incision.

    As I have this extra 'window' cut into my lamina, I can always say that I have a spine with a view!

    Before my neck fusion I asked my neurosurgeon (different surgeon!) how he would check that he got the correct level. He told me that he always takes x-rays first before making an incision to make sure that he got it right.

  • My goodness, Ron you sound like the bionic man with the number of surgeries and what all you've had done!

    I was in la la land when the surgeon was looking at my back, but I would think any surgeon would mark the surgical site fluoroscopically or with standard x-rays before operating.

    Several Epidurals, L4-S1 360 ALIF, Numerous Facet Joint Injections, RFA x2
  • they always marked the leg and signed/initialed etc. had sharpie marks for weeks until it wore off. For the lamenectomy no marks at all on my neck and he did a 3" incision for 1 level. The surgeon I have now said my 3 level fusion won't be as big as the lamenectomy scar.
    One funny point, when I woke up from my knee revision surgery (took partial out and put in full replacement) I had writing and initials on my right butt cheek. I told the surgeon - no wonder they give you soo much anestesia, what else were you-all doing in the OR, next time bring some scratch paper...
    laminectomy c4/c5 2008, ACDF c4-c7 Jan 20 2014 sched
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