المتخصصون في المجالات الطبية

June 20, 2025

Although rare, wrong-site spinal surgery events are devastating for patients when they occur. Spinal surgery practices adopted across Mayo Clinic's organization minimize these risks.

"We've worked to make our processes as ironclad as possible to make sure a wrong-site event never happens," says Chris C. Fox, M.D., a neurosurgeon at Mayo Clinic in Jacksonville, Florida. "We're being proactive because events like this can lead to additional surgery, pain and disability."

The processes developed for spinal surgery also are followed for minimally invasive nonsurgical spinal interventions, such as selective nerve root blocks.

"Even one wrong-level spine procedure is more than unacceptable," says Chandan Krishna, M.D., a neurosurgeon at Mayo Clinic in Phoenix/Scottsdale, Arizona. "We think that the incidence of wrong-level spinal procedures is likely underreported in the literature."

Wrong-site events might arise when patients have transitional spinal anatomy, in which a vertebra exhibits features of both adjacent segments. "About 90% of the population has what we typically consider normal spinal segmentation. But about 10% of the population has a variant anatomy that changes conventional numbering of the spinal vertebrae and can lead to an error at the time of surgery," says Jeffrey A. Stone, M.D., a neuroradiologist at Mayo Clinic's campus in Florida.

A typical example is lumbosacral transitional vertebra. "L5 looks more like how S1 would typically look, or vice versa," Dr. Fox says. "What one specialist might describe as level L5/S1 might be described by a different interpreter as L4/5. That can lead to confusion."

Having an extra rib also can lead to disparate numbering of the thoracic vertebrae. Another challenging area is the cervical thoracic junction. "It's hard to visualize on standard X-rays. Sometimes we have to do an X-ray from a different angle and count ribs — but that can confuse the numbering," says Benjamin D. Elder, M.D., Ph.D., a neurosurgeon at Mayo Clinic in Rochester, Minnesota.

As a large spinal surgery center, Mayo Clinic often treats individuals with disparate spinal anatomy. Mayo Clinic's multidisciplinary approach means that several specialists apply their expertise to each case. The care team might include specialists in neurosurgery, neurology, neuroradiology, orthopedic surgery and pain medicine.

Mayo Clinic's spinal imaging standardizes labeling for enhanced communication. Initial spine localizer imaging is numbered, and the numbered image is archived for reference by all healthcare providers.

"We stick with the gold standard surgical nomenclature of seven cervical, 12 thoracic and five lumbar vertebrae. If a patient has, for example, 11 rib-bearing bodies and six lumbar-type bodies, we label that first lumbar-type body 'T12,' " says Jeffrey S. Ross, M.D., a neuroradiologist at Mayo Clinic's campus in Arizona.

Detailed clinical and surgical notes — starting with a clear description of any transitional anatomy — further ensure accuracy. "The first bullet point in the summary given to clinicians might be 'transitional lumbosacral anatomy.' We put that flag out there," Dr. Ross says. "We then refer the clinicians to a detailed description of the anatomy and its numbering in the case report."

The same practices are applied to imaging performed elsewhere that patients bring with them to Mayo Clinic. "We are very clear about how we name outside imaging when we interpret it and unambiguous when we send any patient to see another specialist for a procedure," Dr. Fox says. "Also, the collaborative nature of our practice means that the multiple specialists caring for a patient's spine are encouraged to pick up the phone and talk to one another if they have any questions."

Marking and pausing

Fiducial markers can guide treatment for individuals with complex spinal anatomy or in areas that are challenging to visualize, such as the thoracic spine. Radiologists might use fluoroscopy to insert a gold seed in the relevant vertebra before surgery. "That gives us a very clear landmark of the level we're at," Dr. Elder says.

During spinal procedures, Mayo Clinic neurosurgeons perform an intraoperative timeout in addition to the standard presurgical pause. "After the exposure is performed, we obtain fluoroscopy imaging to confirm the levels with our radiology colleagues. We visually compare the intraoperative and preoperative images," Dr. Krishna says.

The attending physician makes this confirmation. "But we also usually confirm the level with additional team members participating in the case — residents, fellows and nurses," Dr. Elder says. "If there are still significant questions, we ask the attending radiologist to review the image again."

Intraoperative CT might be performed during particularly challenging procedures, such as when a patient has obesity. "Intraoperative CT allows us to clearly see all the anatomy. There's no guesswork," Dr. Elder says.

The team approach is at the heart of Mayo Clinic's care. Specialists meet regularly in a multidisciplinary spinal conference to discuss complex cases.

"We get multiple perspectives from different specialties to make sure that we're optimizing the patient's care — whether that be with surgery, interventional therapy, integrative medicine or pain rehabilitation," Dr. Fox says. "When you have all that expertise under one roof, you can really do what's right for the patient."

For more information

Refer a patient to Mayo Clinic.