The third patient, who had central spinal stenosis, was treated by decompression alone. However, this is the first study to evaluate the direct medicolegal impact of misplaced pedicle and lateral mass screws on spine surgery in the US and presents important information that may support the routine use of intraoperative imaging confirmation (via 3D fluoroscopy or intraoperative CT) and/or navigated screw placement (either computer- or robot-assisted) as a potential method to decrease the risk of future litigation during spinal fusion procedures. 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. 2020;11:38. You may be trying to access this site from a secured browser on the server. 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. Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England. 2017;42(3):177185. $ = US$; MW = Midwest; NE = Northeast; SE = Southeast; SW = Southwest; W = West. We serve the following localities: Cook County including Arlington Heights, Barrington, Berwyn Township, Chicago, Des Plaines, Glenview, Orland Park, Palos Park, Schaumburg, and Tinley Park; DuPage County including Downers Grove, Naperville, and Bolingbrook; Kane County including Aurora, Elgin and Geneva; Lake County including Waukegan; and Will County including Joliet. Eur Spine J. HHS Vulnerability Disclosure, Help Fishers exact test and the Mann-Whitney U-test were used for the analysis of categorical and continuous data, respectively, except when an unpaired t-test was utilized for analyses related to normalized, nominal, and inflation-adjusted award totals. National Library of Medicine Drs. 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference, 8th Annual Health IT + Digital Health + RCM Conference, 29th Annual Meeting - The Business & Operations of ASCs, The issues spine surgeons are advocating for outside of the operating room, Centinel Spine is now covered by all major payers, What's next for SI joint fusion? MeSH 2002;27(22):24252430. Drafting the article: Sankey. Malpractice liability and defensive medicine: a national survey of neurosurgeons. Acquisition of data: Sankey. 2. 2012;41(2):6973. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? J Pediatr Orthop. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. With increasing pedicle screw usage, the number of patients with misplaced screws will likely increase proportionally. 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. Katonis, Pavlos MD*; Christoforakis, Joseph MD*; Aligizakis, Agisilaos C. MD*; Papadopoulos, Charalampos MD*; Sapkas, George MD, DSc**; Hadjipavlou, Alexander MD*. Kreisman Law Offices has been handling Illinois surgical error lawsuits for individuals and families for more than 35 years in and around Chicago, Cook County and surrounding areas, including Batavia, Bellwood, Deerfield, Evanston, Franklin Park, and Lansing. Conception and design: Sankey, KD Than. Aigner R, Bichlmaier C, Oberkircher L, Knauf T, Knig A, Lechler P, Ruchholtz S, Frink M. BMC Musculoskelet Disord. Call me tomorrow. However, following the spinal fusion, Nyquist began to experience foot drop in her right foot. Spine 8:970981, 1996. 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 ]. A total of 2396 screws were placed accurately (87.96%). and 17.1% of the patients included had at least one screw misplaced. Except for two patients with spinal metastatic disease, all other patients received an iliac crest autologous bone grafts. 29. Plaintiff-awarded cases by US region (left). Patient safety: disclosure of medical errors and risk mitigation, Neurosurgical practice liability: relative risk by procedure type. Mayo Clinic uses the latest robot-assisted technology when indicated to enhance surgical precision in these procedures. Schatlo B, Molliqaj G, Cuvinciuc V, et al. Spine 19:25842589, 1994. A review of medicolegal malpractice suits involving cervical spine: what can we learn or change? 2006;65(4):416421. 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. 2018;29(4):397406. 144 Some error has occurred while processing your request. (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. 19. Under the high-low agreement, Drs. 2017 Mar;5(2):109-116. doi: 10.1016/j.jspd.2016.10.007. One hundred twelve patients were treated using the Cotrel-Dubousset pedicle screw fixation system for degenerative disease (57 patients), trauma (42 patients), infection (eight patients), and tumor (five patients) of the lumbar or thoracolumbar spine. What can spine surgeons do to improve patient care and avoid medical negligence suits? 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. Finally, considering the problems of balance, it seems that failure to properly evaluate any preexisting scoliosis was a main cause of this important complication. Johnston II CE, Ashman RB, Baird AM, Allard RN: Effect of spinal construct stiffness on early fusion mass incorporation: Experimental study. Forty-seven intraoperative and medical complications were observed in 41 patients (36.6%). 5-7 Materials and Methods This is a retrospective study of kyphotic spondylitis tuberculosis (Stb) patients conducted at Fatmawati General Hospital, Jakarta, Indonesia, through the year 2020-2021. Hecht N, Kamphuis M, Czabanka M, et al. 2011;213(5):657667. The radiology results showed that the surgical screw placed at the right L4-5 area had breached the medial wall and was actually extending into the spinal canal. The aim of this study is to evaluate the accuracy of pedicle screw insertion in spondylitis tuberculosis kyphosis correction using a freehand technique. Elizabeth Hofheinz, M.P.H., M.Ed. 32. Spine (Phila Pa 1976). Once the spine is exposed, the appropriate levels of fixation are confirmed with the image intensifier. Presse Med 78:14471448, 1970. States were then grouped by US region and case year by 5-year intervals. 5. 2011;24(1):1519. For more information, please refer to our Privacy Policy. The plaintiff will recover $2.25 million because of a high-low agreement the lawyers entered after closing arguments, the New Jersey Law Journal reports. doi: 10.1097/BRS.0b013e31822a2e0a. In several of the studies in the spinal literature, the contention that instrumentation improves arthrodesis rates, considering that nonunion contributes to a poor outcome in spinal arthrodesis is favored. GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). Neurosurgery. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. (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. In situ spine arthrodesis permits load sharing by the vertebral bodies, preventing fatigue failure of the implant. 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. 2020;162(6):13791387. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. 2018;83(5):9971006. 4. Conclusion: This was followed by pseudarthrosis requiring revision surgery, present in 14.3% (n = 3) and 14.9% (n = 7) of plaintiff- and defendant-awarded cases, respectively (p = 0.99). When grouped by US region, most cases occurred in the Northeast (n = 25, 36.8%), followed by the West (n = 15, 22.1%; Fig. West III JL, Bradford DS, Ogilvie JW: Complications of the variable screw pedicle screw fixation. Back pain/spinal stenosis and neurogenic claudication/radiculopathy were the most frequently reported indications for the index surgery, accounting for 13 (19.1%) and 11 (16.2%) cases, respectively. Reprint requests to Pavlos Katonis, MD, 99 Minoos & Thenon Street, 71305, Heraklion, Crete, Greece. In two patients in the current series, dislodgement of the rods from tulip screws occurred, as reported originally by Edmunds et al. Moffatt-Bruce SD, Ferdinand FD, Fann JI. Although the rate of the reported complications was high, the final outcome of the patients was not affected significantly. Retrospective analysis of reasons and revision strategy for failed thoracolumbar fracture surgery by posterior approach: a series of 31 cases. Subjects were 10,754 patients (73,777 pedicle screws) who underwent PSF at 11 hospitals over 15 years. Clin Orthop 203:4553, 1986. 15. Achieving proper lumbar lordosis, evaluating any preexisting scoliosis, and intraoperative assessment with AP radiographs could prevent balance problems. Saillant G: Etude anatomique des pedicules vertebraux: Application chirurgicale. However, published reports are increasingly demonstrative of the positive effect of pedicle fixation on arthrodesis and successful outcome in the treatment of patients with these disorders. The rate of reoperation for screw misplacement per screw was 0.17%. The third surgical procedure removed the pedicle screws but left the patient in an unfused state with an unstable spine. Fager CA. 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. Yuan et al 37 reported that the use of spinal instrumentation is associated with higher rate of infection (3%6%), neurologic injury (1%5%), instrumentation failure (6%10%), and reoperation (20%), compared with in situ arthrodeses. Fortunately, most of the complications were minor and transient. Results: Personal consequences of malpractice lawsuits on American surgeons. In White AH, Rothman RH, Ray CD (eds). * 33. 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. Yuan HA, Garfin SR, Dickman CA, Mardjetko SM: A historical cohort study of pedicle screw fixation in thoracic, lumbar and sacral spinal fusions. 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. 2,24,28,36. There were nine instrumentation failures at the thoracolumbar area (seven patients), lumbar area (one patient), and lumbosacral area (one patient). The remaining eight patients, including two patients with spinal trauma, five patients with infection, and one patient with a tumor, had anterior and posterior procedures. matte black square deadbolt; roberts point park fishing report; qr code on binax covid test; mff premium character list. 34. What can spine surgeons do to improve patient care and avoid medical negligence suits? 2014;96(4):266270. 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). 15. Would you like email updates of new search results? This study quantifies the rate of screw misplacement on a per-patient basis to highlight its effect on potential morbidity. Per-patient analysis reveals more concerning numbers toward screw misplacement. Although the rate of the reported medical complications was high (36.5%), these did not significantly affect the final clinical outcome of the current patients. Disclaimer. Risk factor analysis showed smaller Cobb angles increased likelihood of all screws being AP. Spine arthrodesis was evaluated with plain AP and lateral radiographs taken 1 year after surgery. Nyquist followed a medical malpractice lawsuit against Dr. Masnyk for his surgical error, alleging that the surgeon had improperly positioned the right L4 pedicel screw which had resulted in a nerve root injury and Nyquists subsequent foot drop. 2012 Feb 1;37(3):E188-94. Zucherman J, Hsu K, Picetti III G, et al: Clinical efficacy of spinal instrumentation in lumbar degenerative disc disease. Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. J Neurosurg. McLaughlin WM, Donnelley CA, Yu K, Gillinov SM, Tuason DA. 2016;25(3):716723. 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. Rovit RL, Simon AS, Drew J, et al. Ann R Coll Surg Engl. However, the highest offer had been a combined $300,000 from the two defendants. 23. These numbers are in line with the current literature. Pedicle instrumentation in the thoracolumbar and lumbar spine is a technically challenging procedure. 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. Long spine fixation was necessary for patients with tuberculous spondylitis and metastatic disease. Screws penetrating the anterior cortex and abutting vascular structures, particularly aortic abutment with left-sided screws, which can lead to erosion and pseudoaneurysms. Conversely, Nyquists foot drop did not resolve after the screw was removed, which begged the question of whether the foot drop was in fact caused by the misplaced screw. Copyright 2023 Becker's Healthcare. Spine fixation included one segment in 27 patients, two segments in 38 patients, three segments in 42 patients, and more than three segments in five patients. Daniels AH, Ruttiman R, Eltorai AEM, et al. Previous biomechanical and clinical studies defining junctional segment problems are lacking and consist mainly of case reports. All Rights Reserved. Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. Epstein NE. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. Defensive medicine: a culprit in spiking healthcare costs. 4). 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). Please enable it to take advantage of the complete set of features! your express consent. Pitfall: Unstable injuries. 38. 2018;41(5):e615e620. J Neurosurg Spine. [] The accuracy for free-hand screw placement technique varies from 69% to 94%. 30. Screws were divided into four categories: screws at risk (SAR), indeterminate misplacements (IMP), benign misplacements (BMP), accurately placed (AP). J Spine Surg. J Am Coll Surg. Studdert DM, Mello MM, Sage WM, et al. Lali Sekhon, Jocelyn Idema & more: 4 spine and neurosurgeons making headlines, Spinal cord stimulation trumps medication for pain reduction 7 takeaways, Dr. Khalid Kurtom on major trends in spinal cord injury surgery. 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. 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. J Neurosurg Spine. Ahmadi SA, Sadat H, Scheufler KM, et al. 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). 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. Spinal fusion procedures are increasingly performed each year, with Deyo et al. Both of these patients complained of thigh pain but refused any additional surgery. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. Litigation resulted in average payouts of $1,204,422 $753,832 between 1995 and 2019, when adjusted for inflation. J Neurosurg Spine. 11. Bookshelf 2005;293(21):26092617. Dr. K. D. Than is a consultant for Bioventus and receives honoraria from DJO and LifeNet Health. Friedlander and Bradley will pay half of the $2.25 million. Spine Deform. 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. Introduction. All the incidental dural tears were repaired immediately and produced no clinical sequelae. Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO CT scanner. shooting in valdosta leaves one dead A Cotrel-Dubousset spinal system (Medtronic Sofamor Danek, Memphis, TN) was used in all patients and the total number of screws used was 658. 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. 7. 2014 Sep;21(3):320-8. doi: 10.3171/2014.5.SPINE13567. 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. The remaining two patients had asymptomatic junctional problems develop after two- and three-segment fusions, at the third and fourth postoperative year, respectively. 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. 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. Lumbar Spine Surgery. Of note, the award amount for one settlement case was undisclosed. PURPOSE This study aimed to compare rates of perioperative complications between robotic-assisted and conventional . 13. Routine CT scans were taken in all patients. A TLIF is a surgical procedure that attempts to fuse vertebrae in order to stabilize the patient's spine. 16,24,28 Simultaneously, the evolution of the surgical techniques has led to increased procedural safety. Hardware problems were those related to the physical change of metal and screw position. Scarone P, Vincenzo G, Distefano D, et al. Louw JA, Dommissee GF, Roos MF: Spinal stenosis following anterior spinal fusion. Krag MH, Beynnon BD, Pope MH, et al: An internal fixator for posterior application to short segment of the thoracic, lumbar, or lumbosacral spine. Three-dimensional printing versus freehand surgical techniques in the surgical management of adolescent idiopathic spinal deformity. 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. 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. Li HM, Zhang RJ, Shen CL. One common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass instrumentation. FOIA 2013;123(9):20992103. Results. J Neurosurg Spine. In 2 patients, misplacement of pedicle screws was recognized intraoperatively and all implants were removed. Thus, we are unable to comment on whether all misplaced screws, particularly when asymptomatic, should be revised in an effort to prevent litigation. In their meta-analysis of nine randomized controlled trials, Li et al. There were 74 men and 38 women, with a mean age of 47 years (range, 1872 years). Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. In four of these patients, bent screws occurred at 8 to 10 months after surgery; in three patients, broken screw necks were seen 1 year after surgery and in two patients, tulip screw plug dislodgments were observed at 4 and 6 months postoperatively, respectively. 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. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. And while the jury debated for about two hours, at the end of its deliberation it sided with the defendants and entered a not guilty verdict. 1). Quinnell RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) In six of these patients with injuries at the thoracolumbar area (four patients with bent screws and two patients with broken screws), the loss of correction ranged from 3 to 4.5 without change of anatomic reduction (Fig 1). Br J Neurosurg. The largest inflation-adjusted payout awarded to the plaintiff ($3,372,185) for nerve root injury occurred in a 36-year-old male who had undergone an L4S1 posterior spinal fusion, which resulted in permanent and direct injury to right L5 and S1 nerve roots, with foot drop and radiculopathy. INCLUDE WHEN CITING DOI: 10.3171/2020.8.FOCUS20600. Stauffer RN, Coventry MB: Posterolateral lumbar-spine fusion: Analysis of the Mayo clinic series. In addition, seven (6.3%) dural tears occurred during the decompression and none occurred during instrumentation. Pedicle screw construct have become one of the most practiced procedure in spinal surgery. 9. The literature gave a range of screw misplacement rates detected on postoperative imaging of between 1% and 18%, with the rate generally considered to be around 10%. Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in Zaleski v Elmhurst Eye Surgery Center. It is an effective procedure in that it provides an almost immediate stabilization of the spine [ 2-5 ]. Complete degeneration of the upper disc developed in two patients who had spinal stenosis and degenerative scoliosis. Start; O firmie; Usugi; Serwis; Realizacje i porady; Kontakt Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation Nickl v. Barry S. Rosen, M.D. Characteristics of medicolegal cases related to misplaced screws in spine surgery. Svider PF, Husain Q, Kovalerchik O, et al. 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.

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