Prior to surgery, neurosurgeon documents his plan, "I think she would benefit from a C5/6/7 cervical arthroplasty" for a C5/6/7 herniated disc.
In the operative report, after performing surgical repair of C5, 6, 7, he notes the following:
Attention was then placed towards what was thought to be the C6-7 disc base which was the disc base below. An
incision was made into the disc space. A discectomy was completed under the operating microscope with a straight
curette and an upgoing curette. The posterior longitudinal ligament was opened with an upgoing curette followed by 1
Miller Kerrison and 2 Miller Kerrison. There was a significant amount of spondylosis at this level as well as kyphosis at
this level. I initially trialed the smaller NuVasive simplify implant. It could not be well visualized on imaging. In
addition I could not place a bigger implant which would normally thought to be possible at the C6-7 disc base.
Because of this I did recount the disc spaces. The patient had abnormal anatomy. The C2-3 autofusion at there on
the counting off to some extent. However, due to the spondylosis and kyphosis it was still felt indicated diffuse this disc
space. This would allow better positioning of the overall lordosis of the neck. At that point the interbody arthrodesis
was completed. A small 6 mm NuVasive peek cage was packed with demineralized bone matrix and tamped into
place. This improved the overall lordosis of the spine. A 22 mm NuVasive Archon plate was then secured with four 13
mm thick screws. This was x-rayed the C7/T1 disc space that was arthrodesed and fused.
Client states that he admitted making a mistake after the surgery. Her neck pain has increased since the surgery. Client's PCP told her that her C7-T1 spine was fine prior to the surgery.
Files:
No questions yet!
Do you believe there might have been medical error?
This case would likely be viewed as below standard of care most likely especially with documented "mistake" admission by the physician. It would benefit from a full pre-op imaging review and all intra-op X-rays/fluoroscopy, and maybe level confirmation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Could be localization error and incorrect fusion level but would benefit from a more detailed review
What makes you a good expert for this case?
I am an academic neurosurgeon with experience in adult and pediatric neurosurgery and spine deformity
How often do you encounter cases similar to this one in your practice?
very rarely do i see similar cases like this
Do you believe there might have been medical error?
Sounds like they did not reconfirm the level and missed the diseased level bc of degeneration. It can sometimes be hard to see the disc spaces intraop. I will say that X-ray can be challenging at C7-T1 and this case sounds a bit complex given the auto fusion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The neck pain can be caused by anything. I would not be able to say if this wrong level mattered.
What makes you a good expert for this case?
I perform a significant amount of cervical spine surgery and localize often.
How often do you encounter cases similar to this one in your practice?
I cannot recall a recent wrong level fusion.
Do you believe there might have been medical error?
From a patient’s perspective, this case represents a wrong-level cervical spine surgery resulting from a failure to properly localize anatomy before proceeding with irreversible surgical steps. The surgeon planned a C5–6 and C6–7 cervical arthroplasty for documented pathology, yet instead performed a discectomy and fusion at C7–T1—a level not identified as symptomatic or diseased preoperatively. The operative note itself reflects uncertainty (“what was thought to be the C6–7 disc space”), indicating that the surgeon proceeded without definitive level confirmation, which is a well-established requirement in spine surgery. The accepted standard of care mandates clear intraoperative imaging and verification of the correct level prior to incision into the disc space; failure to do so constitutes a preventable error. Rather than halting the procedure when visualization was inadequate, obtaining additional imaging, or using adjunct localization techniques, the surgeon continued and performed an unnecessary fusion at the wrong level, exposing the patient to permanent anatomical alteration without therapeutic benefit. This error not only failed to address the patient’s underlying pathology but also introduced new morbidity, manifested by worsened postoperative neck pain, and may compromise future surgical options. The alleged admission of mistake further supports that this was not a judgment call within acceptable standards, but a deviation from the surgical safety principles.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a reasonable basis to believe that the patient’s worsened pain and fusion constitute an injury (cased by an unindicated fusion l performed at C7–T1) a level not previously identified as symptomatic or pathologic. Surgical violation of a normal motion segment (with placement of an interbody cage and anterior plate) can itself generate pain through soft tissue disruption, altered biomechanics, and increased stress at adjacent levels. At the same time, the actual symptomatic levels (C5–6 and C6–7) were not treated, allowing the original pathology to persist. This combination: failure to address the pain generator plus creation of a new structural alteration provides a l plausible mechanism for both persistence and exacerbation of neck pain following the procedure.
What makes you a good expert for this case?
I am a board-certified neurosurgeon (FAANS) with an active practice in spine surgery, including cervical decompression, arthroplasty, and fusion. I routinely manage degenerative cervical conditions and have extensive experience with intraoperative level localization and imaging challenges at the cervicothoracic junction. My clinical and operative experience allows me to evaluate standard of care, surgical decision-making, and causation of injury in cases such as this. I am familiar with medicolegal cases, defending other surgeons as a member of the Medical Review Panel of Louisiana, and I work with some personal injury attorneys on the plaintiffs’s side.
How often do you encounter cases similar to this one in your practice?
I operate over one hundred anterior cervical cases per year, and have done thousands in my career.
Do you believe there might have been medical error?
The surgeon admitted the error, the images confirm the error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a high failure rate of these multi-level fusion cases. Surgeon clearly documents his intra-operative concerns and reason to proceed with the fusion(after recounting the levels). Patient size often makes counting difficult as well(is she a big woman?). There was a definite error. Showing causation would be a temporal relationship, perhaps not a clear anatomical relationship. His description is clearly self-serving. Once you have incised the disc, you have no choice but to proceed with fusion
What makes you a good expert for this case?
Board certified neurosurgeon who has taken trauma call at a level 1 trauma center for decades
How often do you encounter cases similar to this one in your practice?
Cervical fusion cases are frequent(at least weekly). Wrong level operations, rare(I have never cared for any).
Do you believe there might have been medical error?
The surgeon admits to fusing the wrong anatomic level. This is a serious medical error. Standard of care mandates that the surgeon determines and verifies surgical levels at multiple points throughout a spinal fusion procedure to ensure the proper level is addressed. Intraoperative X-ray is a simple way to do this and should always be employed. In addition, it would be important to know what specifically was on the consent form, but if C7-T1 fusion was not listed as a possibility then this is malpractice.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Fusion across the C-T transition (i.e. C7-T1) as a stand alone construct is also considered high risk as junctional levels subsequently bear a greater biodynamic strain and hence often require multi-level fusion (one to 2 levels above and below the area of focus) to ensure a safe construct. This is not mentioned at all in these notes and I am concerned in addition to being a "wrong level" surgery, this patient is at greater risk for construct break down and adjacent segment degeneration having undergone a single level fusion at C7-T1 than shew would have had if she had a single level fusion at the intended level C6-C7.ent above
What makes you a good expert for this case?
I am a dual board certified pediatric and adult neurosurgeon having performed 100s of cases like these.
How often do you encounter cases similar to this one in your practice?
I focus mainly on children now, but I had many many cases like this in my training.
Do you believe there might have been medical error?
It appears the surgeon made an intraoperative decision re fusion the C7-T1 disc space after re-counting the vertebrae and assessing the need for resorting cervical lordosis. The planned disc space was fused, the numbering is what changed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It appears the surgeon made an intraoperative decision re fusion the C7-T1 disc space after re-counting the vertebrae and assessing the need for resorting cervical lordosis. The planned disc space was fused, the numbering is what changed.
What makes you a good expert for this case?
I have performed many anterior cervical spine operations.
How often do you encounter cases similar to this one in your practice?
none lately as my current practice is primarily focused on patients with brain tumors.
Do you believe there might have been medical error?
This is a clear example of a wrong level surgery due to misidentification on fluoroscopy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is not certain that the pain is due to the wrong level surgery, and the extent of harm may not become clear for years as the patient ages and stressing this level continues.
What makes you a good expert for this case?
I am a practicing neurosurgeon with >10 years of experience in cranial and spinal neurosurgery.
How often do you encounter cases similar to this one in your practice?
I have encountered patients like this frequently in my career, though in the last 5 years only a few times per year.
Want to open a case or submit response?
Comments are accepted only from Neurological Surgery experts.