What can spine surgeons do to improve patient care and avoid medical negligence suits? Orthopedics. 2012 Feb 1;37(3):E188-94. 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. 24. The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. 15. Furthermore, 25 patients (22.3%) reported persistent pain in the iliac crest (donor graft site) for several months, for which they were treated with repeated lidocaine injections and analgesics. A total of 69 patients (mean age, 67.416 . (%), Pseudarthrosis requiring revision surgery. All the operations were done by one surgeon (PK). In addition, studies have shown that over 85% of malpractice claims are either dismissed or settled out of court,14 which likely results in a high degree of underreporting. PURPOSE This study aimed to compare rates of perioperative complications between robotic-assisted and conventional . 2020;162(6):13791387. Reprint requests to Pavlos Katonis, MD, 99 Minoos & Thenon Street, 71305, Heraklion, Crete, Greece. The case facts centered on a spinal surgery the 34 year-old plaintiff had undergone at Central DuPage Hospital. The cost of defensive medicine on 3 hospital medicine services, Defensive medicine in neurosurgery: the Canadian experience, Review of neurosurgery medical professional liability claims in the United States, A nine-year review of medicolegal claims in neurosurgery, Malpractice risk according to physician specialty, Neurosurgical experience with malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999 through 2003, Descriptive analysis of state and federal spine surgery malpractice litigation in the United States, Malpractice litigation following spine surgery, Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis, Malpractice claims in spine surgery in Germany: a 5-year analysis, On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim, Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England, Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort, It is easier to confuse a jury than convince a judge: the crisis in medical malpractice, Determining legal responsibility in otolaryngology: a review of 44 trials since 2008, Legal liability in iatrogenic orbital injury, Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study, Malpractice issues in neurological surgery. Neurosurgery. 25. Plaintiff's expert was prepared to testify at trial that these complaints are characteristic of a malpositioned screw impinging upon a neural structure. NCI CPTC Antibody Characterization Program. The patient had to undergo a subsequent surgery to remove the pedicles. In the current series, including general complications, only 48 patients (43%) had no notable complication and the remaining 64 patients (57%) had one or more complications. Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Nationally Recognized Regionally Dominant Contact Us Now For a Free Consultation Over $850 Million in Verdicts and Settlements Home Articles Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction However, the misplacement of pedicle screws can lead to disastrous complications. A misplacement rate of more than 20 % (129 misplaced screws out of 608) seems to be unacceptable compared to only 4.5 % misplacements when using CT-navigation leading to the conclusion that pedicle screw instrumentation in the middle and upper thoracic area should be carried out with the help of navigation only. Categorical and continuous data are described as frequency (percentage) and median (interquartile range), respectively, except for the use of mean standard deviation for award amounts since both nominal and inflation-adjusted award totals passed (alpha = 0.05) the DAgostino-Pearson omnibus normality test. 2022 Jun;8(2):234-241. doi: 10.21037/jss-22-28. 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. Mohar J, Vali M, Podovovnik E, Mihali R. Eur Spine J. A high-low agreement is a settlement in which a defendant agrees to pay the plaintiff a minimum recovery in exchange for the plaintiff agreeing to accept a maximum amount regardless of the trial's outcome. Am J Transl Res. Epub 2022 Oct 29. The last two patients had a T12L1 fracture-dislocation and a L4L5 spondylolytic spondylolisthesis at the site of plug dislodgments. In unstable injuries, the segments above and below the level of injury may have a different orientation of the pedicle trajectory due to . Eur Spine J. 2020;11:38. Judgment information associated with a defendant (surgeon) versus plaintiff (patient) ruling, trial versus settlement versus arbitration decision, award amount, and time to decision or case closure from index surgery was also recorded. Inaccurate pedicle screw placement is relatively common even when placement is performed under fluoroscopic control. Although the rate of the reported complications was high, the final outcome of the patients was not affected significantly. Sethi MK, Obremskey WT, Natividad H, et al. Although pedicle screw fixation opened a new horizon of spinal surgery by providing rigid fixation of the spine, it is a technically demanding procedure with potential complications including medical complications, hardware and technical problems, and long-term changes of junctional motion segments. Critically revising the article: all authors. The average age of the patients was 47 years and the average followup was 35 months. Unable to load your collection due to an error, Unable to load your delegates due to an error. Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort. J Neurosurg. Two-dimensional (2D) fluoroscopy-guided percutaneous pedicle screw (PPS) placement is currently the most widely applied instrumentation for minimally invasive treatment of spinal injuries requiring stabilization. Patient safety: disclosure of medical errors and risk mitigation. Surg Neurol. Likewise, research shows that breaches still occur when these tools are used,33,40 and some studies did not find a difference in pedicle breach rates compared to those with traditional fluoroscopic and freehand techniques.33 Ultimately, misplaced instrumentation is a risk of any spinal fusion surgery, and a thorough discussion of these risks, as well as the alternative management options, is essential to maintain high-quality patient care and to avoid litigation. Elizabeth Hofheinz, M.P.H., M.Ed. Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. The https:// ensures that you are connecting to the 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. Potential complications may include increased pain, infection, or mechanical . 38. Of note, while only 38.2% (n = 26) of cases in our study mentioned the use of intraoperative radiographic confirmation, only one of these cases reported that the misplaced screw had been caught prior to leaving the operating room, which had resulted in an inadvertent dural tear and L5 nerve root injury. Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants Irwin v. Alan Loren, M.D. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders, deformities, and trauma. You are talking one of the most complicated area of the law. Spine (Phila Pa 1976). 2018;29(4):397406. Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation Nickl v. Barry S. Rosen, M.D. 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. In 2 patients, misplacement of pedicle screws was recognized intraoperatively and all implants were removed. leg pain. Int Orthop 20:3542, 1996. Call Us Now For a Free Consultation | Toll Free: 800.583.8002 | Local: 312.346.0045, Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants , Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation , Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in, $75 Million Jury Verdict in Failure to Timely Diagnose Stroke, $18 Million Jury Verdict in Late Diagnosis of Breast Cancer, $300,000 Settlement for Excessive Use of Radiation, Chicago Medical Malpractice Lawyer Kreisman Law Offices Home, Contact Illinois Personal Injury Attorney Kreisman Law Offices. Todd NV. Intraoperative pedicle fractures requiring further points of fixation. Spine 18:11601172, 1993. The accuracy of pedicle screw placement using intraoperative image guidance systems. Moreover, local court rulings are not included in the Westlaw Edge database; however, this is unlikely to present meaningful bias given that malpractice claims are generally filed in state courts. Similar to our findings, prior studies have shown that settlements result in lower payouts than cases that are ultimately taken to trial,7,14,15,30 with awards ranging from $125,000 to $9,000,000 compared to $134,000 to more than $38,000,000.7,15 Nevertheless, the true financial toll on spine surgery is largely unknown given that 85% of cases are dismissed or settled out of court, with undisclosed amounts.14 Likewise, substantial time is spent and costs, including legal and administrative, are incurred before judgment, as noted above. Smith TR, Hulou MM, Yan SC, et al. 19. The rate of misplaced pedicle screws ranges from 1.1% to 28.8%, 10 although neurologic injury from misdirected pedicle screws has been reported to occur in 0% to 12% of patients. This step in implant evolution was inevitable, because prior phases of implant development did not control each plane of motion segment stress. Clipboard, Search History, and several other advanced features are temporarily unavailable. Results. The remaining two patients had asymptomatic junctional problems develop after two- and three-segment fusions, at the third and fourth postoperative year, respectively. Comparetto, Esq., 727-328-7900, www.florida-malpractice-lawyers.com. Scarone P, Vincenzo G, Distefano D, et al. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. All Rights Reserved. Thus, in the current study we aimed to describe this impact in the US, as well as to suggest a potential method for mitigating the problem. McLaughlin WM, Donnelley CA, Yu K, Gillinov SM, Tuason DA. Br J Neurosurg. reporting that the number of Medicare patients who underwent a complex lumbar spine fusion for spinal stenosis increased 15-fold, from 1.3 persons per 100,000 Medicare persons in 2002 to 19.9 in 2007.31 Similarly, a study by Rajaee et al. Spine 16:576579, 1991. 16,24,28 Simultaneously, the evolution of the surgical techniques has led to increased procedural safety. Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. 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. The rate of misplaced pedicle screws ranges from 1.1% to 28.8%, 10 although neurologic injury from misdirected pedicle screws has been reported to occur in 0% to 12% of patients. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? 2007;106(6):11081114. The development of the transpedicle screw has provided control of the vertebral motion segment in each plane, resisting any type of load. Pedicle instrumentation in the thoracolumbar and lumbar spine is a technically challenging procedure. 27. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Several studies have shown that spine surgery is at the highest risk for litigation among the surgical subspecialties.12,29 The majority of claims are related to technical and procedural errors,29 including misplaced pedicle and/or lateral mass screws. Dr. K. D. Than is a consultant for Bioventus and receives honoraria from DJO and LifeNet Health. Statistical analysis: Sankey. Hecht N, Kamphuis M, Czabanka M, et al. Rovit RL, Simon AS, Drew J, et al. The standard imaging technique for pedicle screw insertion is two-dimensional images obtained from C-arm-type X-ray fluoroscopy. In addition, hardware failures were observed in 12 patients (10.7%), junctional problems were seen in five patients (4.5%), problems in the instrumented segments were seen in 39 patients (34.7%), and problems of balance occurred in five patients (4.5%). Hadjipavlou A, Enker P, Dupuis P, Katzman S, Silver J: The causes of failure of lumbar transpedicular spinal instrumentation and fusion: A prospective study. In patients with degenerative conditions, all of the affected segments were included in the instrumentation and each vertebra was fixed with two pedicle screws. 7. Epub 2021 Aug 28. Copyright © 2023 Becker's Healthcare. demonstrated that the number of hospital discharges for spinal fusion increased 2.4 times (137%) from 174,223 to 413,171 (p < 0.001) between 1998 and 2008.32 The true frequency of malpositioned pedicle and lateral mass screws is likely underestimated in spine surgery given the fact that the majority of misplaced screws, as well as the potential complications related to them, are not reported in practice and may be clinically silent. 2012;37(1):6776. Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo. Two patients had an acute infection develop for which they required operative intervention with irrigation and debridement. 2016;124(5):15241530. Accuracy of C2 pedicle screw placement using the anatomic freehand technique. The medical malpractice suit Ayala v. Friedlander, M.D., claimed that a March 2011 lumbar fusion surgery performed by neurosurgeon Marvin Friedlander, MD, and orthopedic spine surgeon Douglas Bradley, MD, strayed from the accepted standards of care because a pedicle screw was placed in the wrong location. 3). Unilateral nonunion was seen in three patients (2.7%), associated with implant failure in one of the patients. Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. Spine 13:696706, 1988. Fager CA. 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. 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. Epub 2014 Jun 13. Each side was judged separately. Dr. K. D. Than is a consultant for Bioventus and receives honoraria from DJO and LifeNet Health. In addition, the median time to judgment is substantial, particularly for defendant verdicts, spanning over 4.5 years from the time of surgery. INCLUDE WHEN CITING DOI: 10.3171/2020.8.FOCUS20600. 2012;21(suppl 2):S196S199. The patient had subsequent coronal imbalance and degeneration of the upper disc. Thu, May 27th, 2021. 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. 2018;18(2):209215. Hardware problems were those related to the physical change of metal and screw position. 2014;20(6):636643. Spine (Phila Pa 1976). 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. In the current series, there were no cases of screw misplacement or vascular or neurologic complications caused by implant application. Spinal fusion procedures are increasingly performed each year, with Deyo et al. JAMA. One hundred twelve consecutive patients were entered into a retrospective study of instrumented thoracolumbar, lumbar, and lumbosacral spinal arthrodesis at our institution, between September 1994 and January 1999. Dr. Shaffrey holds patents with, receives royalties from, and is a consultant for Medtronic, NuVasive, and Zimmer Biomet; is a stockholder in NuVasive; is a consultant for K2M, Stryker, SI Bone, and In Vivo; and has received grants from the ISSG, DePuy Synthes, and AO Spine. Complications were classified as general, hardware-related, problems associated with the instrumented segments, junctional level problems, and problems related with balance (Table 2). Eur Spine J. However, following the spinal fusion, Nyquist began to experience foot drop in her right foot. Intraoperative and postoperative complications were recorded by the authors and the results were evaluated by an independent observer. In the Kane County medical malpractice lawsuit of Melissa Nyquist v. Dr. Taras Masnyk and DuPage Neurosurgery, S.C., 06 L 421, the plaintiffs attorney was unable to convince the jury that the plaintiffs medical complications were caused by the defendants negligence. Spine 6:263267, 1981. With pedicle shapes and sizes varying wildly in the scoliotic spine, misplacement of a screwas well as and under- or oversizingare real possibilities in spine surgery. 8600 Rockville Pike Materials and Methods Sixty . and transmitted securely. Spine 17:834837, 1992. Defendant-awarded cases by US region (right). J Bone Joint Surg 62A:13021307, 1980. 2013;32(1):111119. Examples of both laterally and medially misplaced lumbar pedicle screws are provided in Fig. Spine Deform. Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients. 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. 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. Guillain A, Moncany AH, Hamel O, et al. The instrumentation and bone graft were left in place in these patients (total infection rate, 2.7%). Epub 2014 Apr 4. Unfortunately, the plaintiffs attorney was unable to offer an alternative theory of surgical negligence that would refute the defendants explanation. Svider PF, Husain Q, Kovalerchik O, et al. FOIA There were 74 men and 38 women, with a mean age of 47 years (range, 1872 years). The patient suffered permanent nerve damage as a result of the puncture. One hundred four of the 112 patients had a posterior procedure. Spine 18:18621866, 1993. 2021 Nov 26;22(1):986. doi: 10.1186/s12891-021-04860-y. Brodsky AE: Post-laminectomy and post-fusion stenosis of the lumbar spine. Under the high-low agreement, Drs. Li HM, Zhang RJ, Shen CL. All Rights Reserved. Summary of background data: Pedicle screw placement is a common procedure. Plaintiff-awarded cases by US region (left). 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. However, we did not observe any screw breakage in patients with a degenerative lumbar spine, and the absence of broken screws in this series is because arthrodesis in almost all patients occurred in situ. Conclusion: shooting in valdosta leaves one dead 2014 Sep;21(3):320-8. doi: 10.3171/2014.5.SPINE13567. Pitfall: Unstable injuries. [] Computer-assisted computed tomography (CT) techniques have improved the overall accuracy for pedicle screw placement, and has reduced complication rates. Methods: * Nottmeier EW, Seemer W, Young PM. 21. Steffee AD, Brantigan JW: The variable screw placement spinal fixation system: Report of a prospective study of 250 patients enrolled in Food and Drug Administration clinical trials. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Steinmann JC, Herkowitz HN: Pseudarthrosis of the spine. Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. Nevertheless, research has shown that screws are misplaced in approximately 14%55% of cases using the standard techniques (freehand and 2D fluoroscopic guidance) employed by most spine surgeons,21,33 resulting in injury in approximately 1%8% of cases.21 In addition to the avoidable procedural risk to the patient, each misplaced screw carries the threat of future litigation, as reported above. These risks can be minimized by the judicious use of instrumentation by experienced surgeons for specific indications as supported by the literature. When adjusted for inflation, these values increased to $1,330,201 $882,023 versus $970,832 $381,619, respectively (p = 0.32; Fig. Spine J. Careers. To prevent the development of pseudarthrosis, we think it is important for surgeons to apply the following five technical principles: the proper-sized pedicle screw has to be inserted on the first attempt; repeated manipulation in setting instruments must be avoided; anterior penetration of the screw into the sacrum and insertion of two screws in each side are advocated for fixing the lumbosacral junction; industrious and detailed decortication of the posterior elements must be developed fully; and the use of autologous bone graft is recommended. Spine 18:23252326, 1993. This occurred on only one side and the correction achieved by the instrumentation was maintained. Screw misplacement. 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. (A) Anteroposterior and (B) lateral radiographs taken 1 year after surgery show upper screw breakage in the application of a short Cotrel-Dubousset construct in a T12 burst fracture. Spine 15:908912, 1990. They both had motor deficits from which 1 patient recovered completely. Pedicle screw instrumentation is widely used for the stabilization of the subaxial cervical, thoracic, and lumbar spine. Neurosurgical practice liability: relative risk by procedure type. To prevent general complications, it is evident that precise and careful soft tissue handling, proper irrigation, and debridement during and after surgery, decrease of operative time, and proper patient monitoring postoperatively must be done. Can Postoperative Radiographs Accurately Identify Screw Misplacements? $ = US$; MW = Midwest; NE = Northeast; SE = Southeast; SW = Southwest; W = West. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. Spine 6:615619, 1981. Spine 15:1114, 1990. The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion. The amount awarded was not significantly different across US regions (p = 0.9; Fig. N Engl J Med. 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. 4. West III JL, Bradford DS, Ogilvie JW: Complications of the variable screw pedicle screw fixation. Conception and design: Sankey, KD Than. Waddell G, Kummell EG, Lotto WN, et al: Failed lumbar disc surgery and repeat surgery following industrial injuries. Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in Zaleski v Elmhurst Eye Surgery Center. 37. However, 5-10% of those misplaced screws are cause for concern." "To rectify this, we must have access to imaging devices during the procedure. Study design: Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. 12. However, the misplacement of pedicle screws can lead to disastrous complications. 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). 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. Adjusted for age and preoperative Cobb angle, patients with a higher misplacement rate were more likely to have screws . The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). However, the medicolegal impact of misplaced screws on spine surgery has not been directly reported in the literature. Ahmadi SA, Sadat H, Scheufler KM, et al. It argued that the foot drop was unavoidable and due to the surgeons need to manipulate the right L5 nerve root in order to remove Nyquists herniated disc during the spinal fusion surgery. 31. A total of 2396 screws were placed accurately (87.96%). Problems at the junctions of the instrumented spine were seen in five patients (4.5%). This patient recovered completely in 6 weeks. Krag MH, Beynnon BD, Pope MH, et al: An internal fixator for posterior application to short segment of the thoracic, lumbar, or lumbosacral spine. Disclosures Dr. Karikari is a consultant for NuVasive, Globus, Johnson & Johnson, and DePuy and receives a spine fellowship fund from NuVasive. Spinal fusion in the United States: analysis of trends from 1998 to 2008. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. All these problems were observed only just above the upper instrumentation level and all were observed in patients older than 55 years. doi: 10.1097/BPO.0000000000001828. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. To investigate intraoperative reinsertion of percutaneous pedicle screw (PPS) with intraoperative CT-based navigation and to evaluate the rate of deviation of PPS at postoperative radiographic examination. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation.
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