Most surgery in wrong spot done on spine

The Boston Globe—July 30, 2008

Massachusetts surgeons have operated on the wrong location 38 times since 2006, with spine surgeries accounting for more mistakes than any other locations, prompting the state to take action in organizing an official inquiry as well as a blueprint to reduce further error.

Mistakes in surgeries involving the spine are particularly prevalent because the spine is a challenging surgical field, made up of vertebrae that look almost identical to one another. Each vertebra is little more than an inch tall, with only a small separation between the structures.

“You say how could you do a wrong level?” said Frank P. Cammisa Jr., M.D., chief of the spine service at 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 mistakes, doctors count the vertebrae manually and take multiple X-rays of the spine to provide a surgical road map.

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