Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis. 21. Pedicle screw accuracy in thoracolumbar fractures- is routine postoperative CT scan necessary? Inaccurate pedicle screw placement is relatively common even when placement is performed under fluoroscopic control. This patient recovered completely in 6 weeks. 2014 Sep;21(3):320-8. doi: 10.3171/2014.5.SPINE13567. Screws penetrating the anterior cortex and abutting vascular structures, particularly aortic abutment with left-sided screws, which can lead to erosion and pseudoaneurysms. Nyquist had requested the defendants offer, which in retrospect was perhaps a poor decision in light of the Kane County jurys verdict. Neurologic injury. Fager CA. 1. A high-low agreement is a settlement in which a defendant agrees to pay the plaintiff a minimum recovery in exchange for the plaintiff agreeing to accept a maximum amount regardless of the trial's outcome. Health Aff (Millwood). 3. However, the misplacement of pedicle screws can lead to disastrous complications because of the close proximity to neural tissue and the surrounding vessels, although rare, serious complications have been reported, such as dural tear, nerve-root irritation, neural injury . and transmitted securely. Pedicle screw insertion in the thoracolumbar spine. West III JL, Bradford DS, Ogilvie JW: Complications of the variable screw pedicle screw fixation. Except for two patients with spinal metastatic disease, all other patients received an iliac crest autologous bone grafts. In our opinion, these problems may be prevented by applying the following principles: limitation of spine arthrodesis to the pathologic levels, inclusion of already extensive changes at the level above or below the planned arthrodesis into the arthrodesis, restoration of postoperative sagittal and coronal alignment, and avoidance of impingement syndrome from the adjacent nonfused facets. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. Summary of background data: FOIA The rate of misplaced pedicle screws ranges from 1.1% to 28.8%, 10 although neurologic injury from misdirected pedicle screws has been reported to occur in 0% to 12% of patients. Several studies have shown that spine surgery is at the highest risk for litigation among the surgical subspecialties.12,29 The majority of claims are related to technical and procedural errors,29 including misplaced pedicle and/or lateral mass screws. 2014;96(4):266270. Plaintiff award amounts were adjusted for inflation as of April 2020 using an online inflation calculator provided by the US Bureau of Labor Statistics (https://www.bls.gov/data/inflation_calculator.htm). $ = US$. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. Mohar J, Vali M, Podovovnik E, Mihali R. Eur Spine J. 2013;34(6):699705. The largest inflation-adjusted payout awarded to the plaintiff ($3,372,185) for nerve root injury occurred in a 36-year-old male who had undergone an L4S1 posterior spinal fusion, which resulted in permanent and direct injury to right L5 and S1 nerve roots, with foot drop and radiculopathy. Mean amounts awarded SD to plaintiffs by jury trial (n = 13) versus settlement/arbitration (n = 7), adjusted for inflation as of April 2020. to maintaining your privacy and will not share your personal information without
In their meta-analysis of nine randomized controlled trials, Li et al. 22. 15. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. Show more. Eur Spine J. your express consent. Junctional problems were recorded as pathologic changes of the adjacent motion segments, just above and below the instrumented and fused segments. 5. Despite this problem, the clinical result was excellent. 2018;83(5):9971006. Amount awarded to plaintiffs by US region, adjusted for inflation as of April 2020. Study supervision: Goodwin, Karikari, Shaffrey, Abd-El-Barr, KD Than. The plaintiff will recover $2.25 million because of a high-low agreement the lawyers entered after closing arguments, the New Jersey Law Journal reports. This study has shown that percutaneous insertion of pedicle screws in the lumbar spine is a safe and reliable technique, and despite the low misplacement rate of only 6.6%, it should be kept in mind that the surgical procedure is technically demanding and should be performed only by experienced spine surgeons. Surg Neurol Int. South Med J 62:17, 1969. Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in Zaleski v Elmhurst Eye Surgery Center. Call Us Now For a Free Consultation | Toll Free: 800.583.8002 | Local: 312.346.0045, Cook County Surgeons Cut Common BIle Duct During Surgery, But Jury Finds for Defendants , Illinois Jury Finds in Favor of Doctor in Gallbladder Surgery that Led to Fatal Bowel Perforation , Debate Over Extent of Eye Damage Following Implant Lens Surgery Leads to $1 Million Verdict in, $75 Million Jury Verdict in Failure to Timely Diagnose Stroke, $18 Million Jury Verdict in Late Diagnosis of Breast Cancer, $300,000 Settlement for Excessive Use of Radiation, Chicago Medical Malpractice Lawyer Kreisman Law Offices Home, Contact Illinois Personal Injury Attorney Kreisman Law Offices. The purpose of current study was to analyze the complications and problems during and after pedicle screw fixation for various spinal disorders and trauma. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Unilateral nonunion was seen in three patients (2.7%), associated with implant failure in one of the patients. This decision must be made on a case-by-case basis at the surgeons and patients discretion after a thorough discussion of the associated risks and benefits of revision surgery. In unstable injuries, the segments above and below the level of injury may have a different orientation of the pedicle trajectory due to . Please do not include any confidential or sensitive information in a contact form, text message, or voicemail. The defense pointed to the lack of evidence that the screw had ever come into contact with the L5 nerve root. 2016;102(2):358362. One of the patients had a late wound infection develop that was treated by radical debridement and removal of instrumentation. Routine CT scans were taken in all patients. 14. NCI CPTC Antibody Characterization Program. matte black square deadbolt; roberts point park fishing report; qr code on binax covid test; mff premium character list. Sub-analysis of adolescent idiopathic scoliotic patients showed no curve or patient characteristic that correlated with IMP or SAR. Am J Orthop. Examples of both laterally and medially misplaced lumbar pedicle screws are provided in Fig. Importantly, these advanced technologies are not always readily available or the standard of care and cannot supplant a thorough understanding of operative anatomy, a high-quality surgical technique, and general complication-avoidance measures. In the current series, there were no cases of screw misplacement or vascular or neurologic complications caused by implant application. Spine 6:615619, 1981. 2013;32(1):111119. Steffee AD, Brantigan JW: The variable screw placement spinal fixation system: Report of a prospective study of 250 patients enrolled in Food and Drug Administration clinical trials. Two patients with associated injuries in the lower limbs had deep venous thrombosis develop, three patients had pneumonia develop, and four patients with neurologic impairment had urinary tract infections develop. 6. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. Patient safety: disclosure of medical errors and risk mitigation. The cost of defensive medicine on 3 hospital medicine services. Hecht N, Kamphuis M, Czabanka M, et al. Segal J. It is indicated that screws medially misplaced at a distance greater than 2-mm, especially 4 mm, may be a cause of negative effects on the neural structure and should be removed during the early phase of the postoperative period, even among patients without postoperative neurological abnormalities. Two-dimensional (2D) fluoroscopy-guided percutaneous pedicle screw (PPS) placement is currently the most widely applied instrumentation for minimally invasive treatment of spinal injuries requiring stabilization. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. The site is secure. Statistical analysis: Sankey. Introduction. Disc space narrowing was the most common problem after instrumented arthrodesis and was observed in 27 patients (24.1%). Lehmann TR, LaRocca HS: Repeat lumbar surgery: A review of patients with failure from previous lumbar surgery treated with spinal canal exploration and lumbar spine fusion. Elizabeth Hofheinz, M.P.H., M.Ed. However, 5-10% of those misplaced screws are cause for concern." "To rectify this, we must have access to imaging devices during the procedure. Methods. Studdert DM, Mello MM, Sage WM, et al. government site. Previous biomechanical and clinical studies defining junctional segment problems are lacking and consist mainly of case reports. A retrospective review of charts, x-rays (XRs) and computed tomography (CT) scans was performed. Some error has occurred while processing your request. I won't be at the office but I will check my voice mail. sharing sensitive information, make sure youre on a federal Using Low-Dose, Biplanar Imaging to Reduce Screw Misplacement. Agarwal N, Gupta R, Agarwal P, et al. concluded that the robot-assisted technique was significantly more accurate than the traditional freehand technique.39 Despite the learning curve and initial cost of obtaining technologies such as 3D fluoroscopic devices, intraoperative CT, or robotic navigational systems, the routine use of these technologies for intraoperative imaging confirmation and potential revision of misplaced screws may help spine surgeons avoid inadvertent iatrogenic morbidity for their patients and potential litigation. Malpractice claims in spine surgery in Germany: a 5-year analysis. Personal consequences of malpractice lawsuits on American surgeons. Epub 2021 Aug 28. Sarwahi V, Ayan S, Amaral T, Wendolowski S, Gecelter R, Lo Y, Thornhill B. Spine Deform. Excessive hemorrhage occurred in two patients (1.8%) with coagulation disorders. In this example, the surgeon replaced the misplaced screw prior to leaving the operating room, which arguably played a significant role in the jury ruling in favor of the defendant (surgeon). 7. The cost of defensive medicine on 3 hospital medicine services, Defensive medicine in neurosurgery: the Canadian experience, Review of neurosurgery medical professional liability claims in the United States, A nine-year review of medicolegal claims in neurosurgery, Malpractice risk according to physician specialty, Neurosurgical experience with malpractice litigation: an analysis of closed claims against neurosurgeons in New York State, 1999 through 2003, Descriptive analysis of state and federal spine surgery malpractice litigation in the United States, Malpractice litigation following spine surgery, Medical malpractice in orthopedic surgery: a Westlaw-based demographic analysis, Malpractice claims in spine surgery in Germany: a 5-year analysis, On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim, Malpractice litigation and the spine: the NHS perspective on 235 successful claims in England, Placement of thoracolumbar pedicle screws using three-dimensional image guidance: experience in a large patient cohort, It is easier to confuse a jury than convince a judge: the crisis in medical malpractice, Determining legal responsibility in otolaryngology: a review of 44 trials since 2008, Legal liability in iatrogenic orbital injury, Spine neurosurgeons facing the judicialization of their profession: disenchantment and alteration of daily practicea qualitative study, Malpractice issues in neurological surgery. One hundred twelve patients were treated using the Cotrel-Dubousset pedicle screw fixation system for degenerative disease (57 patients), trauma (42 patients), infection (eight patients), and tumor (five patients) of the lumbar or thoracolumbar spine. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. doi: 10.1097/BRS.0b013e31822a2e0a. Image intensification and the technique recommended by Weinstein et al 32 was used for screw placement in the lumbar vertebrae, whereas Chopin blocks (Medtronic Sofamor Danek) with two screws diverging bilaterally were used for sacral fixation. Ann R Coll Surg Engl. Complete degeneration of the upper disc developed in two patients who had spinal stenosis and degenerative scoliosis. However, the impact of robotic-assisted spinal fusion on patient outcomes is less clear. Luque ER: Segmental spinal instrumentation of lumbar spine. Thirty-five (27.56%) had IMP and 18 (14.17%) had SAR. J Bone Joint Surg 62A:13021307, 1980. To prevent the development of pseudarthrosis, we think it is important for surgeons to apply the following five technical principles: the proper-sized pedicle screw has to be inserted on the first attempt; repeated manipulation in setting instruments must be avoided; anterior penetration of the screw into the sacrum and insertion of two screws in each side are advocated for fixing the lumbosacral junction; industrious and detailed decortication of the posterior elements must be developed fully; and the use of autologous bone graft is recommended. We also investigated the effect of bone mineral density (BMD), diameter of pedicle screws, and the region of spine on the pullout strength of pedicle screws. Erwin WD, Dickson JH, Harrington PR: Clinical review of patients with broken Harrington rods. 4). Accuracy of pedicle screw insertion by AIRO intraoperative CT in complex spinal deformity assessed by a new classification based on technical complexity of screw insertion. On average, physicians spend nearly 11 percent of their 40-year careers with an open, unresolved malpractice claim. Please try after some time. Under the high-low agreement, Drs. Likewise, research shows that breaches still occur when these tools are used,33,40 and some studies did not find a difference in pedicle breach rates compared to those with traditional fluoroscopic and freehand techniques.33 Ultimately, misplaced instrumentation is a risk of any spinal fusion surgery, and a thorough discussion of these risks, as well as the alternative management options, is essential to maintain high-quality patient care and to avoid litigation. Level of evidence: Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. Din RS, Yan SC, Cote DJ, et al. However, following the spinal fusion, Nyquist began to experience foot drop in her right foot. These numbers are in line with the current literature. Each case was then carefully screened for relevance and sufficient data. Overall reported screw misplacement is low, but it does not reflect the potential impact on patient morbidity. Scarone P, Vincenzo G, Distefano D, et al. Reprint requests to Pavlos Katonis, MD, 99 Minoos & Thenon Street, 71305, Heraklion, Crete, Greece. However, the highest offer had been a combined $300,000 from the two defendants. This step in implant evolution was inevitable, because prior phases of implant development did not control each plane of motion segment stress. 2011;365(7):629636. Hardware problems were those related to the physical change of metal and screw position. Rev Chir Orthop Reparatrice Appar Mot 62:151160, 1976. Results: A total of 2724 screws were placed in 127 patients. Each side was judged separately. These complications may have resulted from powerful bending movement acting on the screw at its entry point to the bone. Neurosurgical practice liability: relative risk by procedure type. Procedural errors led to combined payouts totaling $124,943,933 in neurosurgery claims between 2003 and 2012 in a study looking at data from the Physician Insurers Association of America Data Sharing Project.10 However, our study is the first to report the direct medicolegal impact of screw misplacement on US spine surgery, with 30.9% of judgments/settlements in favor of the plaintiff, resulting in average payouts of $1,204,422 $753,832 per claim. 3. McAfee PC, Weiland DJ, Carlow JJ: Survivorship analysis of pedicle spinal instrumentation. All case demographics are summarized in Table 1. Cerebrospinal fluid fistulas. Phone/Fax: 30-2810-318361; E-mail: [emailprotected]. Plaintiff's expert was prepared to testify at trial that these complaints are characteristic of a malpositioned screw impinging upon a neural structure. As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiffs spine. However, the misplacement of pedicle screws can lead to disastrous complications. Spine 16(8 Suppl):S422427, 1991. Spine 18:983991, 1993. Spine 17:349355, 1992. Johnston II CE, Ashman RB, Baird AM, Allard RN: Effect of spinal construct stiffness on early fusion mass incorporation: Experimental study. The rod is held in place by "pedicle screws," which the surgeon must insert into the pedicles. However, published reports are increasingly demonstrative of the positive effect of pedicle fixation on arthrodesis and successful outcome in the treatment of patients with these disorders. Edwards CC: Spinal screw fixation of the lumbar and sacral spine: Early results treating the first 50 cases. 20th Annual Spine, Orthopedic & Pain Management-Driven ASC Conference, 8th Annual Health IT + Digital Health + RCM Conference, 29th Annual Meeting - The Business & Operations of ASCs, The issues spine surgeons are advocating for outside of the operating room, Centinel Spine is now covered by all major payers, What's next for SI joint fusion? All Rights Reserved. 26 They support that after a lengthy symptom-free period, segments next to a fused segment can break down and the segment next to the adjacent segment is almost as likely to break down as the adjacent segment. Conversely, Nyquists foot drop did not resolve after the screw was removed, which begged the question of whether the foot drop was in fact caused by the misplaced screw. Rynecki ND, Coban D, Gantz O, et al. Preparation. Facebook Google Plus Youtube RSS Email. This device was used with an early version of the Cotrel-Dubousset instrumentation to provide sacral fixation and it is rarely used since the more widespread use of newer spine fixation systems. However, despite the apparent widespread use of pedicle system fixation, few studies of problems and particularly complications have been published. Cookie Policy. 31. Medical malpractice litigation has made a significant impact on spine surgery, with many spine surgeons avoiding complex cases or practicing other defensive medicine tactics in an effort to avoid being sued.5 Moreover, the majority of neurosurgeons spend more than 10% of their annual revenue on malpractice insurance,1,14 and the excessive financial risk of litigation is even leading some insurers to no longer offer coverage to spine surgeons.19 A 2011 study in the New England Journal of Medicine found that 19.1% of neurosurgeons are named as a defendant in a malpractice suit each year (highest of any specialty).12 Moreover, 88% of physicians in high-risk specialties, like neurosurgery, are involved in a lawsuit by age 45, increasing to a concerning 99% by 65 years of age.12 Such litigation places a substantial financial, temporal, and emotional burden on physicians in high-risk specialties, with studies showing that up to 72% of neurosurgeons1 admitted that their fear of litigation significantly influenced their practice,25 with many avoiding high-risk patients altogether.1 Similarly, Nahed et al. The .gov means its official. J Neurosurg Spine. 2018;43(14):984990. 1. Saillant G: Etude anatomique des pedicules vertebraux: Application chirurgicale. Dr. Goodwin has received grants from the Burroughs Wellcome Fund, North Carolina Spine Society, and Robert Wood Johnson Harold Amos Medical Faculty Development Program and the NIH/NINDS K12 NRCDP Physician Scientist Award. Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Nationally Recognized Regionally Dominant Contact Us Now For a Free Consultation Over $850 Million in Verdicts and Settlements Home Articles Misplacement of Pedicle Screws Leads to Years of Pain and Opioid Addiction Pedicle screws have been used to treat spinal disorders, including those caused by spinal cancer, congenital anomalies, trauma, and chronic pain syndromes. One hundred four of the 112 patients had a posterior procedure. The median time to case closure was 56.3 (35.267.2) months when ruled in favor of the plaintiff (i.e., patient) compared to 61.5 (51.477.2) months for defendant (surgeon) verdicts (p = 0.117). JAMA. 3). In the remaining patients, the standard construct was three-segment fixation spanning four vertebrae and three discs, two above and one below the fractured vertebra, using six screws. It argued that the foot drop was unavoidable and due to the surgeons need to manipulate the right L5 nerve root in order to remove Nyquists herniated disc during the spinal fusion surgery. It should be used by experienced and qualified surgeons who are familiar with the pitfalls associated with its use. 2,24,28,36. The development of the transpedicle screw has provided control of the vertebral motion segment in each plane, resisting any type of load. As compared to cases in 19952009, those in 20102019 resulted in a significantly higher average nominal payout to plaintiffs ($776,439 $74,460 vs $1,506,000 $385,527, p = 0.028). Li HM, Zhang RJ, Shen CL. Misplaced pedicle and lateral mass screws result in a considerable risk of malpractice litigation against spine surgeons. 2012;7(6):e39237. Dr. K. D. Than is a consultant for Bioventus and receives honoraria from DJO and LifeNet Health. Feb. 16, 2021 Accurate placement of pedicle screws is key to avoiding the potential complications of spinal fusion surgery and improving overall spinal fixation. shooting in valdosta leaves one dead Dalenberg DD, Asher MA, Robinson RG, Jayaraman G: The effect of a stiff spinal implant and its loosening on bone mineral content in canines. Clin Orthop 203:4553, 1986. Laryngoscope. were excluded from analysis. J Am Coll Surg. The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. Spine 17:834837, 1992. Sethi MK, Obremskey WT, Natividad H, et al. HHS Vulnerability Disclosure, Help Figure 1: Lower thoracic pedicles provide the firm purchase of the pedicle screw from a lateral starting point and 10-15 degrees convergent angle Surgical technique "Free Hand" pedicle screw placement [50] Our "Free Hand" technique is equivalent for lumbar and Nyquist followed a medical malpractice lawsuit against Dr. Masnyk for his surgical error, alleging that the surgeon had improperly positioned the right L4 pedicel screw which had resulted in a nerve root injury and Nyquists subsequent foot drop. Spine 14:472476, 1989. On April 6, a Union County, N.J., jury awarded a plaintiff $4.5 million over a botched spine surgery. With increasing pedicle screw usage, the number of patients with misplaced screws will likely increase proportionally. Eur Spine J. A rod is used to hold the vertebra together to allow fusion to occur. Unfortunately, the plaintiffs attorney was unable to offer an alternative theory of surgical negligence that would refute the defendants explanation. Spine 13:10121018, 1988. Zdeblick 38 also reported an overall arthrodesis rate of 65% in patients without instrumentation, 77% in patients with semirigid fixation, and 95% in patients with a rigid constrained screw-rod system. Hardware-related failures were observed in 12 patients (10.7%). GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). 2014;174(11):18671868. Two patients had an acute infection develop for which they required operative intervention with irrigation and debridement. Katonis PG, Kontakis GM, Loupasis GA, et al: Treatment of unstable thoracolumbar and lumbar spine injuries using Cotrel-Dubousset instrumentation. Ann Thorac Surg. Five patients had uneventful early postoperative course. It has a great developing technique that is used for fixation and fusion in spine surgery. There were nine instrumentation failures at the thoracolumbar area (seven patients), lumbar area (one patient), and lumbosacral area (one patient). Cotrel Y, Dubousset J, Guillaumat M: New universal instrumentation in spinal surgery. Disclosures Dr. Karikari is a consultant for NuVasive, Globus, Johnson & Johnson, and DePuy and receives a spine fellowship fund from NuVasive. Several limitations should be carefully considered when interpreting our results. 2020;162(6):13791387. Neurosurgery. 39. Spine 19(20 Suppl):2279S2296, 1994. Drafting the article: Sankey. Defensive medicine in U.S. spine neurosurgery. 2002;27(22):24252430. The third surgical procedure removed the pedicle screws but left the patient in an unfused state with an unstable spine. Review of neurosurgery medical professional liability claims in the United States. An official website of the United States government. Mayo Clinic uses the latest robot-assisted technology when indicated to enhance surgical precision in these procedures. 2020;11:38. Malpractice issues in neurological surgery. Presse Med 78:14471448, 1970. J Spine Surg. Screw Malposition: Are There Long-term Repercussions to Malposition of Pedicle Screws? The contact form sends information by non-encrypted email, which is not secure. Todd NV. It is easier to confuse a jury than convince a judge: the crisis in medical malpractice. A total of 2724 screws were placed in 127 patients. In four of these patients, bent screws occurred at 8 to 10 months after surgery; in three patients, broken screw necks were seen 1 year after surgery and in two patients, tulip screw plug dislodgments were observed at 4 and 6 months postoperatively, respectively. Spine 6:263267, 1981. 30. Administrative/technical/material support: Mehta, Wang, KD Than. L3S1 spine arthrodesis was done in the first patient but the correction of scoliosis was not sufficient and coronal imbalance persisted after surgery, which accelerated the degeneration of the level just above the arthrodesis. This retrospective study analyzes the complications and the problems developed during and after pedicle screw fixation in patients with spinal disorders and trauma. Department of Neurosurgery, Spine Division, Duke University Medical Center, Durham, North Carolina; and, Malpractice liability and defensive medicine: a national survey of neurosurgeons, Defensive medicine among high-risk specialist physicians in a volatile malpractice environment, Defensive medicine: a culprit in spiking healthcare costs, Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study, Defensive medicine in U.S. spine neurosurgery, Personal consequences of malpractice lawsuits on American surgeons. 2005;293(21):26092617. Subjects were 10,754 patients (73,777 pedicle screws) who underwent PSF at 11 hospitals over 15 years. Pedicle screws are used by spine surgeons as part of a fusion in which two adjacent bones in the spine are combined together as one. 5-7 Materials and Methods This is a retrospective study of kyphotic spondylitis tuberculosis (Stb) patients conducted at Fatmawati General Hospital, Jakarta, Indonesia, through the year 2020-2021. To evaluate the accuracy of pedicle screw placement using a novel classification system to determine potentially significant screw misplacement. In addition, the median time to judgment is substantial, particularly for defendant verdicts, spanning over 4.5 years from the time of surgery. Spine 19:25842589, 1994. The highly litigious environment within healthcare has resulted in a majority of physicians practicing defensive medicine,15 often leading to burnout6,7 and an exorbitant ethical and financial burden on medical and surgical care.7,8 In 2008, medical liability accounted for $55.6 billion, representing 2.4% of the United States (US) healthcare expenditures that year,5,7,9,10 and the pervasive practice of defensive medicine may cost up to $210 billion annually in the US.5 A similar trend has been observed in Europe.11, Neurosurgery is the specialty most frequently affected by lawsuits and the fear of litigation, both in the US and abroad,12 with spine surgery at the forefront.11,1317 As a result, spine surgeons are nearly three times more likely than nonspine surgeons to practice defensive medicine, defined as the avoidance of high-risk procedures and the provision of unnecessary services and assessments beyond what is clinically necessary in an effort to avoid litagation.5 The average time to judgment in a case is approximately 5.1, 5.0, and 3.4 years for defendant verdicts, plaintiff rulings, and settlements, respectively.7,15 As a result, physicians spend an average of 11% of their careers dealing with one or more open malpractice claims.18 Neurosurgeons are especially impacted, spending an average of 27.2% of their careers in an open lawsuit.10. You may be trying to access this site from a secured browser on the server. Operative information including fusion level, number of levels fused, level of misplaced screw(s), single versus multiple misplaced screw(s), presence of known CSF leakage, and primary injury due to screw misplacement was also collected. As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiff's spine.