Most surgery in wrong spot done on spine
11 such cases found in state since 2006
By Stephen Smith, Globe Staff | July 30, 2008
Surgeons in Massachusetts have operated in the wrong location on patients 38 times since 2006, with botched spine surgeries accounting for more of the mistakes than any other type of operation, according to a Globe review of state documents.
A single hospital, New England Baptist, accounted for four of the 11 bungled spine surgeries in the state, with the errors happening during a 10-month period. No deaths or severe disabilities resulted from any of the faulty spine surgeries, state health authorities said. In some of the 11 patients, the wrong vertebrae were fused; in others, the wrong bulging disc was removed.
In three of the cases at the Baptist, surgeons discovered the error in the operating room and performed the correct procedure while the patient's spine was still exposed.
Still, after the Globe began inquiring about the mistakes at New England Baptist, state health authorities said they were so concerned that they ordered the hospital to hire an outside consultant to review the cases as well as its blueprint for reducing errors.
"Our goal is to drive the rate of these events to zero," said Paul Dreyer, director of healthcare safety and quality at the state Department of Public Health, who added that lessons learned at the Baptist, which he said performs 20 percent of the state's spinal fusions, could help patients across the state.
Dreyer described the state's action as unusual but said it fit into a broader nationwide campaign to reduce serious errors in hospitals, clinics, and doctors' offices - mistakes that exact a high cost, both in medical and economic terms. According to a federal report this week, surgical errors alone may bloat employers' healthcare costs by as much as $1.5 billion a year.
The movement to eliminate blunders has gained momentum in recent months, with some hospital administrators - already required under state law to report serious mistakes - pledging to go further by making it public when their doctors err. Earlier this month, Beth Israel Deaconess Medical Center revealed that an orthopedic surgeon had operated on the wrong side of a patient.
And private health plans and government programs such as Medicare have declared they will no longer pay for costs associated with preventable errors.
The mistakes that have received the most attention, such as amputating the wrong limb, are relatively easy to prevent - "no-brainers," one lawyer branded them. Operating room teams mark the knee or hip to be repaired and require everyone in the surgical suite to acknowledge that the correct procedure is taking place on the correct spot on the correct patient.
Those same measures are used in spine surgery, but they're not enough. Because the spine is a complex latticework of bones, ligaments, and spongy material, identifying the right surgical site can be substantially more challenging than making sure a biopsy is performed on the correct breast, for example.
"While it would be a clear departure from the standard of care to operate at the wrong level of the spine, there are more reasons - perhaps not good reasons - why that could happen," said Marc L. Breakstone, a Boston malpractice lawyer currently representing a client who sued over a spine operation performed earlier this decade. "But it's still inexcusable; it shouldn't happen."
Two Boston-area hospitals, New England Baptist and Lahey Clinic in Burlington, were responsible for more than half of the errant spine surgeries in the past 2 1/2 years, according to public records requested by the Globe.
A Lahey spokesman declined to comment in detail about the nature of the hospital's two wrong-site surgeries, but state officials confirmed that they were spine surgeries. A statement from Lahey described the patients as "doing well."
While not disclosing the names of the patients or surgeons involved because of privacy laws, representatives of the Baptist agreed to explain spine surgery and some of the factors contributing to the four errors that happened between May of last year and this March.
In all four cases, patients came to the Baptist to have vertebrae fused, an operation designed to provide stability to a spine left weak and painful by arthritis, bone degeneration, tumors, or other ailments.
Unlike other bone structures in the body, the 33 vertebrae appear remarkably similar. One spine surgeon described it as akin to driving into a suburban neighborhood where all the houses look identical, distinguished only by the occasional shutter or flowerbox.
Each vertebra is little more than an inch tall, with only a small separation between the bony structures.
"You say how could you do a wrong level?" said Dr. Frank P. Cammisa Jr., chief of the spine service at the Hospital for Special Surgery in New York. "You can see where it would be hard to determine what vertebrae you're working on."
To avoid a mistake, doctors manually count the vertebrae and routinely take multiple X-rays of the patient to provide a surgical road map.
When problems happen, specialists said, it can be because a radiologist failed to interpret an X-ray correctly or a surgeon's method for counting vertebrae conflicted with the process used by the radiologist.
And the architecture of the spine becomes more complex in patients whose spines are injured or abnormal, said the Baptist's chief of neurosurgery, Dr. Eric Woodard, who was not directly involved in the four faulty procedures.
"For instance, thin bone, osteoporotic bone can make actual identification on the X-ray during surgery very, very tricky because the bony edges are not nearly as clear as in, say, a younger person with thicker bone," he said.
Three of the four patients at the Baptist had complicated spinal anatomy, said Maureen Broms, the hospital's vice president for healthcare quality and patient safety. The hospital performs about 2,000 spine surgeries a year, including some of the state's most difficult.
"When you look at these cases, altered anatomy is a consideration," Broms said, "but we don't see it as an excuse. To that patient, it's important that we get it right."
In three of the four cases, vertebrae were fused directly above the intended site; in one case, it was directly below. Woodard said that in one instance, medical films were misinterpreted, and in the others, the errors stemmed from inaccurately translating the X-ray information to the patients' bodies.
The mistakes were discovered in three patients as surgeons put screws or plates in place and took X-rays to check their placement; they were billed for only one spinal fusion. The error involving the fourth patient was discovered months later during a follow-up scan, and hospital officials said it is their understanding that the patient plans to have the correct operation performed by the same surgeon.
Specialists said that fusing the wrong vertebrae can sometimes compromise patients' mobility, but the hospital said the patients would experience no perceptible difference in flexion or motion.
None of the medical team members faced sanctions from the state or the hospital. Earlier this year, the Baptist created a task force of specialists to recommend measures to reduce errors, and one of those will be implemented starting Aug. 11: Surgeons during the operation will be able to call radiologists elsewhere in the hospital and send a real-time image to get a second opinion.
Dr. Sohail Mirza, an orthopedic surgeon at the University of Washington in Seattle, said patients can help prevent errors, too.
"The patient should not hesitate to ask the surgeon, especially if it's spine surgery, 'How are you going to check that it's the right level?' " he said.
Emergency surgery in March of 2006 for spinal infection of L 2 and L 3. During surgery, discovered I had Cauda Equina Syndrome. Spine became unstable after surgery and had 360 fusion with 10 pedicle screws, plates and rods in April of 2007.