Wrong site spine surgery in the U.K.: a review of current practice

Abstract

Wrong site spine surgery is a rare but serious complication. The scale of the problem in the U.K. and the current practice of spine surgeons in localising the level whilst performing routine spine surgery is unknown. As these events are rare and their nature very disparate, it is necessary to identify whether there are any common themes to be able to take effective steps to mitigate this risk. A review was undertaken of the wrong site spine surgery incidents submitted to StEIS (Strategic Executive Information System), the system used to report and monitor the progress of Serious Incident investigations across the NHS. Subsequently a survey of the Society of British Neurosurgeons was undertaken to answer some of the questions which arose from this review. Up to half of spine surgeons surveyed by the SBNS admit to having performed wrong site spine surgery. 40 percent of wrong site surgery reported to NHSE was at the L4/5 level. What exactly constitutes wrong level spine surgery is not universally accepted by spine surgeons. The critical factors in causing wrong site spine surgery in the U.K. are explored. It is hoped that the results from this study would improve training, lead to better policies and support investment in trying to reduce this complication