Audit of a Standard Operating Procedure to Prevent Wrong-Level Lumbar Spinal Surgery with Intra-Operative X-Ray

Introduction: One of the major errors that can be encountered by a spinal surgeon is operating at the wrong level/side.However, wrong-level spinal surgery is considered a 'never-event' and is under-reported.Many surgeons have traditionally adopted the technique of palpating or "counting" from L5-S1 to determine the operative level in lumbar spine procedures without necessarily the use of intraoperative X-ray control.Most surgeons these days; however, use X-rays or fluoroscopy during the surgery.There is no universal standard operating procedure (SOP) for the use of X-rays or fluoroscopy during spinal surgery and the compliance of the surgeons for any local SOP is unknown.Aim: The audit primarily intended to check the compliance with an established local SOP using X-ray to identify lumbar spinal level.We also determined the accuracy of lumbar spine level marking by palpation.We also tried to quantify the intra-operative error rate following pre-operative X-ray level marking.Overall, the optimum role of X-rays was determined for adequate level of lumber decompression.Methods: The audit was performed as a prospective clinical audit within a single neurosurgical department.Data collected from theatre logbook, medical notes and picture archive and communication system (PACS).An established local SOP for use of X-rays during spinal surgery was used as a benchmark to audit local practice.Cycle 1: Every lumbar discectomy and decompression from June to November 2015 (6 months) was obtained.The findings were presented in our local clinical effectiveness meeting with the aim check local practice and suggest improvements.Cycle 2: Re-audit a further 6 months, December 2015 to May 2016, to see the significance of the change implemented.Results: In the first cycle, one patient did not receive pre-operative X-ray.While all other patients received pre-operative X-rays, the number of exposures was available in only 71% of patients, out of which 39% required one exposure, 43% required two exposures, 16% required three exposures and 2% required four exposures.Twenty eight cases (13.9%) were recorded to have intra-operative X-ray level checked due to doubt, out of which 22 cases were found to be on an incorrect level.In the second cycle, all patients received pre-operative X-rays and the number of exposures was recorded for all, out of which 52% required one exposure, 32% required two exposures, 13% required three exposures and 3% required four exposures.Twenty cases (9.7%) were recorded to have intra-operative X-ray level checked due to an arising doubt, out of which only 7 were found to be on an incorrect level.