Per-patient analysis showed 23 (18.11%) of patients had all screws AP. There were no observed cases of screw misplacement outside the pedicle on routine AP and lateral radiographs. This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Percentage of cases per US region (center). All the incidental dural tears were repaired immediately and produced no clinical sequelae. Rovit RL, Simon AS, Drew J, et al. Pedicle screw accuracy in thoracolumbar fractures- is routine 2017;27(4):470475. J Spinal Disord Tech. Acquisition of data: Sankey. Spine surgery has been disproportionately impacted by medical liability and malpractice litigation, with the majority of claims and payouts related to procedural error. Neurosurgery. All Rights Reserved. The radiology results showed that the surgical screw placed at the right L4-5 area had breached the medial wall and was actually extending into the spinal canal. Can Postoperative Radiographs Accurately Identify Screw Misplacements? Surg Neurol. Seabury SA, Chandra A, Lakdawalla DN, Jena AB. Conclusion: This retrospective analysis of 68 closed medicolegal cases related to misplaced screws in spine surgery showed that neurosurgeons and orthopedic spine surgeons were equally named as the defendant (n = 32 and 31, respectively), and cases were most commonly due to misplaced lumbar pedicle screws (n = 41, 60.3%). Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO CT scanner. Please enable it to take advantage of the complete set of features! Most of these complications were minor and with the exception of two misplaced screws, did not contribute to the occurrence of neurologic impairment or severe pain. A total of 69 patients (mean age, 67.416 . However, the impact of robotic-assisted spinal fusion on patient outcomes is less clear. Scarone P, Vincenzo G, Distefano D, et al. With pedicle shapes and sizes varying wildly in the scoliotic spine, misplacement of a screwas well as and under- or oversizingare real possibilities in spine surgery. As part of the surgery, Dr. Taras Masnyk inserted four metal screws into the plaintiff's spine. The pedicle screw system is widely used in spine surgery, and it provides rigid fixation and leads to successful subsequent deformity correction and bony fusion. Thoracic pedicle screw placement: Free-hand technique - Bioline 2022 Sep 15;14(9):6323-6331. eCollection 2022. 1,12,19,22 The largest series of adjacent segment breakdown was reported by Schlegel et al. 28. Koktekir E, Ceylan D, Tatarli N, Karabagli H, Recber F, Akdemir G. Spine J. Re: malpositioned pedicle screw resulting in additional surgery and disability. Elsamadicy AA, Sergesketter AR, Frakes MD, Lad SP. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. Complications and Problems Related to Pedicle Screw Fixation - LWW Clinical Orthopaedics and Related Research, Get new journal Tables of Contents sent right to your email inbox, The Association of Bone and Joint Surgeons, Complications and Problems Related to Pedicle Screw Fixation of the Spine, Articles in Google Scholar by Pavlos Katonis, MD, Other articles in this journal by Pavlos Katonis, MD, Privacy Policy (Updated December 15, 2022). 30. 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 Spine 8:970981, 1996. Pedicle screw insertions are commonly used for posterior fixation to treat various spine disorders. 8600 Rockville Pike One hundred four of the 112 patients had a posterior procedure. This occurred on only one side and the correction achieved by the instrumentation was maintained. Study design: 2021 Nov;9(6):1541-1548. doi: 10.1007/s43390-021-00377-5. Examples of both laterally and medially misplaced lumbar pedicle screws are provided in Fig. Ann R Coll Surg Engl. Each case was then carefully screened for relevance and sufficient data. Additional survey data have shown that 50% of physicians exhibit at least a temporary loss of self-esteem after a malpractice claim, and at least 25% experience depression.22 As stated above, the average neurosurgeon spends 27.2% of his or her entire career in an open malpractice claim,10 and each case can take an average of 5.1, 5.0, and 3.4 years for defendant verdicts, plaintiff rulings, and settlements, respectively.7,15 Likewise, neurosurgeons have a higher risk than practitioners in other specialties of being named in multiple malpractice suits given the particularly high-risk nature of the specialty.10 Even when found in favor of the defendant (surgeon), each case ultimately takes a substantial emotional and financial toll on the physician(s) involved. The states with the most cases included California (n = 10, 14.7%), New York (n = 6, 8.8%), Pennsylvania (n = 6, 8.8%), and Illinois (n = 5, 7.3%; Table 2). Surg Neurol Int. INCLUDE WHEN CITING DOI: 10.3171/2020.8.FOCUS20600. Cases involving wrong-level or -side surgery, implant malfunction, or other misplaced spinal instrumentation (e.g., interbody cases, rods, surgical instruments, etc.) Judgment information associated with a defendant (surgeon) versus plaintiff (patient) ruling, trial versus settlement versus arbitration decision, award amount, and time to decision or case closure from index surgery was also recorded. Rothberg MB, Class J, Bishop TF, et al. Under this theory of liability, the plaintiff needed to not only establish that she had experienced foot drop, a fact that no one was disputing, but that it was caused by the defendants negligence. JAMA. We attribute the 24.1% disc space narrowing in the instrumented segments mainly to the severe injury of the disc and communication of the end plate in burst fractures, which could accelerate the disc degeneration and narrowing. 2011;306(10):1088. Hardware problems were those related to the physical change of metal and screw position. and 17.1% of the patients included had at least one screw misplaced. Copyright 1944-2023 American Association of Neurological Surgeons, Copy this link, or click below to email it to a friend. 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. PMC 2018;18(2):209215. 2013;32(1):111119. Moreover, several cases stated that the surgeon used only the anteroposterior or the lateral view, but not both, and the plaintiffs counsel used this information in support of their claim. The patient had subsequent coronal imbalance and degeneration of the upper disc. 4. The contact form sends information by non-encrypted email, which is not secure. 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. Schatlo B, Molliqaj G, Cuvinciuc V, et al. Twenty-one patients (18.8%) had thoracolumbar injuries, and loss of immediate postoperative deformity correction ranged from 1.4 to 4.5. The total number of reoperations for MPS and patient clinical data were obtained from medical records at each hospital. 2016;25(3):716723. Jury awards $4.5M over misplaced pedicle screw during spine surgery: 5 things to know Spine Monday, May 7th, 2018 Post Listen Text Size On April 6, a Union County, N.J., jury awarded a plaintiff $4.5 million over a botched spine surgery. 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. The screws were needed to stabilize the spine and fix the fused vertebrae in place. 13 Whitecloud et al 35 reported 15% neurologic complications, 5% being caused by incorrect screw placement. This demonstrates technical ability but does not represent the impact of screw misplacement on individual patients. Pullout performance comparison of pedicle screws based on cement Defensive medicine: a culprit in spiking healthcare costs. Results. were excluded from analysis. Fortunately, most of the complications were minor and transient. Spine (Phila Pa 1976). 17,18,31,39 Edwards 6 showed that solid arthrodesis developed in 96% of patients without previous surgery, whereas 84% of patients having secondary operations experienced a similar result. Pedicle screw insertion in the thoracolumbar spine. J Neurosurg Spine. Waddell G, Kummell EG, Lotto WN, et al: Failed lumbar disc surgery and repeat surgery following industrial injuries. Spine arthrodesis was evaluated with plain AP and lateral radiographs taken 1 year after surgery. Clipboard, Search History, and several other advanced features are temporarily unavailable. The majority of screws were misplaced in the lumbar spine for both plaintiff- and defendant-awarded cases (66.7% vs 57.4%, respectively, p = 0.564; Table 1). Epstein NE. Study supervision: Goodwin, Karikari, Shaffrey, Abd-El-Barr, KD Than. Int Orthop 20:3542, 1996. Introduction. Disclaimer. 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. Show more. One of the common means of doing so is to place a screw into each of two adjacent spinal bones (vertebrae), and then a rod between them. Drs. What can spine surgeons do to improve patient care and avoid medical negligence suits? Malpractice liability and defensive medicine: a national survey of neurosurgeons. Malpositioned pedicle screw resulting | Legal Advice - LawGuru Am J Transl Res. 2014;20(2):196203. Under the high-low agreement, Drs. 19. Instrumentation removal is an option for patients with successful arthrodesis, but remains controversial. Three-dimensional printing versus freehand surgical techniques in the surgical management of adolescent idiopathic spinal deformity. Pullout performance comparison of pedicle screws based on cement application and design parameters Tolga Tolunay, Cemile Bagl, Teyfik Demir, Mesut E Yaman, and Arslan K Arslan Proceedings of the Institution of Mechanical Engineers, Part H: Journal of Engineering in Medicine 2015 229: 11 , 786-793 Download Citation Results: A total of 47 (69.1%) cases resulted in a decision for the defendant and 21 (30.9%) for the plaintiff. 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 2012;21(suppl 2):S196S199. Crawford MJ, Esses SI: Indications for pedicle fixation: Results of NASS/SRS faculty questionnaire: North American Spine Society and Scoliosis Research Society. Dr. Friedlander did not order a CT or MRI until January 2013, when the pedicle screw was found to be in the wrong location and a failed fusion was diagnosed, according to the suit. The patient had to undergo a subsequent surgery to remove the pedicles. Please try after some time. 2014;96(4):266270. Don't jump in get legal help. Lumbosacral pedicle screw placement using a fluoroscopic pedicle axis 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. Thus, meaningful efforts to limit the rate of misplaced pedicle and lateral mass screws, such as the routine use of intraoperative imaging confirmation and/or computer- or robot-assisted navigation, should be carefully considered. 1. J Neurosurg Spine. The medical malpractice suit Ayala v. Friedlander, M.D., claimed that a March 2011 lumbar fusion surgery performed by neurosurgeon Marvin Friedlander, MD, and orthopedic spine surgeon Douglas Bradley, MD, strayed from the accepted standards of care because a pedicle screw was placed in the wrong location. Data is temporarily unavailable. 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. Incidence and costs of defensive medicine among orthopedic surgeons in the United States: a national survey study. Call me tomorrow. In two patients in the current series, dislodgement of the rods from tulip screws occurred, as reported originally by Edmunds et al. Melissa Nyquist required a lumbar back fusion for a herniated disc at the L4-5 level. Saillant G: Etude anatomique des pedicules vertebraux: Application chirurgicale. Erwin WD, Dickson JH, Harrington PR: Clinical review of patients with broken Harrington rods. National Library of Medicine The accuracy rate of pedicle screw (PS) placement varies from 85% to 95% in the literature. 2014;21(3):320328. 2013;34(6):699705. Lawsuit information regarding the plaintiffs age at the time of the malpractice claim, sex, postoperative complaint, indication for index surgery, defendant surgeon specialty (neurosurgery vs orthopedics), and delayed diagnosis or treatment, as well as case location by state and case year, was obtained. West III JL, Bradford DS, Ogilvie JW: Results of spinal arthrodesis with pedicle screw-plate fixation. Litigation resulted in average payouts of $1,204,422 $753,832 between 1995 and 2019, when adjusted for inflation. To reinforce spinal fixation, we have proposed a construct with segmental pedicle fixation two levels above and one level below the injured level and insertion of a screw deep into the pedicle, providing more contact area between screw head and bone and reducing the moment arm of the bending stress. Among the plaintiff-awarded cases, 13 (61.9%) were decided by jury trial, 7 (33.3%) by settlement, and 1 (4.8%) by arbitration. In addition, seven (6.3%) dural tears occurred during the decompression and none occurred during instrumentation. The accuracy of pedicle screw placement using intraoperative image guidance systems. However, following the spinal fusion, Nyquist began to experience foot drop in her right foot. GraphPad Prism version 6.01 for Windows was used for all descriptive analyses (GraphPad Software). Pedicle screw placement accuracy impact and comparison between grading HHS Vulnerability Disclosure, Help In six of these patients with injuries at the thoracolumbar area (four patients with bent screws and two patients with broken screws), the loss of correction ranged from 3 to 4.5 without change of anatomic reduction (Fig 1). doi: 10.1097/BRS.0b013e31822a2e0a. The site is secure. J Neurosurg Spine. Characteristics of medicolegal cases related to misplaced screws in spine surgery. Makhni MC, Park PJ, Jimenez J, et al. We serve the following localities: Cook County including Arlington Heights, Barrington, Berwyn Township, Chicago, Des Plaines, Glenview, Orland Park, Palos Park, Schaumburg, and Tinley Park; DuPage County including Downers Grove, Naperville, and Bolingbrook; Kane County including Aurora, Elgin and Geneva; Lake County including Waukegan; and Will County including Joliet. Roy-Camille R, Saillant G, Mazel C: Internal fixation of the lumbar spine with pedicle screw plating. These risks can be minimized by the judicious use of instrumentation by experienced surgeons for specific indications as supported by the literature. Malpractice claims in spine surgery in Germany: a 5-year analysis. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults, Spinal fusion in the United States: analysis of trends from 1998 to 2008, Safety and efficacy of pedicle screw placement using intraoperative computed tomography: consecutive series of 1148 pedicle screws, The accuracy of pedicle screw placement using intraoperative image guidance systems, 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, Pedicle screw placement accuracy using ultra-low radiation imaging with image enhancement versus conventional fluoroscopy in minimally invasive transforaminal lumbar interbody fusion: an internally randomized controlled trial, Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine: a retrospective cohort study of 263 patients, Accuracy and workflow of navigated spinal instrumentation with the mobile AIRO, Accuracy of pedicle screw placement and clinical outcomes of robot-assisted technique versus conventional freehand technique in spine surgery from nine randomized controlled trials: a meta-analysis, Safety and accuracy of robot-assisted versus fluoroscopy-guided pedicle screw insertion for degenerative diseases of the lumbar spine: a matched cohort comparison, Verdict/Settlement Search and Inclusion/Exclusion Criteria, Plaintiff Claim and Index Surgery Information, Impact of Medical Malpractice on Neurosurgeon and Orthopedic Surgeon Careers, Financial Burden of Medical Malpractice Claims Related to Misplaced Pedicle and/or Lateral Mass Screws, Frequency of Misplaced Pedicle and Lateral Mass Screws in Spine Surgery, Strategies to Improve the Accuracy of Screw Placement in Spine Surgery, Top 25 Cited Gamma Knife Surgery Articles - Trigeminal Neuralgia, Top 25 Cited Gamma Knife Surgery Articles - Volume 111, https://doi.org/10.3171/2020.8.FOCUS20600, https://www.bls.gov/data/inflation_calculator.htm, Volume 49 (2020): Issue 5 (Nov 2020): Medicolegal issues in neurosurgery, Single vs multiple misplaced screw(s), no. Accuracy of C2 pedicle screw placement using the anatomic freehand Patient Suffers Permanent Nerve Damage From Spinal Surgery Quinnell RC, Stockdale HR: Some experimental observations of the influence of a single lumbar floating fusion on the remaining lumbar spine. Comparetto, Esq., 727-328-7900, www.florida-malpractice-lawyers.com. 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. Continued clinical experience with various pedicle screw implant systems has led to ongoing improvements in system design to minimize implant failure rates and to improve ease of system application. Harrington PR, Tullos HS: Reduction of severe spondylolisthesis in children. Notwithstanding these concessions, the MDU argued that misplacement of pedicle screw tracts was common in surgery of this kind, even in experienced and competent hands. However, the misplacement of pedicle screws can lead to disastrous complications. In the Kane County medical malpractice lawsuit of Melissa Nyquist v. Dr. Taras Masnyk and DuPage Neurosurgery, S.C., 06 L 421, the plaintiffs attorney was unable to convince the jury that the plaintiffs medical complications were caused by the defendants negligence. 3. 2011;213(5):657667. Spine 13:10121018, 1988. I won't be at the office but I will check my voice mail. 6. Dr. Karikari is a consultant for NuVasive, Globus, Johnson & Johnson, and DePuy and receives a spine fellowship fund from NuVasive. Mississippi Appellate Court Affirms Medical Malpractice Defense Verdict 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. Nominal and inflation-adjusted award payouts were higher for trial verdicts than for settlement/arbitration, with a nominal average of $1,140,473 $841,683 versus $788,533 $306,186 awarded to the plaintiff, respectively (p = 0.30). First, this is a retrospective analysis of cases obtained from the web-based Westlaw Edge legal research database. Fager CA. Sub-analysis of adolescent idiopathic scoliotic patients showed no curve or patient characteristic that correlated with IMP or SAR. The instrumentation and bone graft were left in place in these patients (total infection rate, 2.7%). 14. Spine 18:18621866, 1993. The incidence of screw failure, which can occur despite solid arthrodesis, 7 in the current series was 8% and mainly involved patients with thoracolumbar injury. It should be used by experienced and qualified surgeons who are aware of the pitfalls associated with its use. The physician ordered an MRI of the lumbar spine which showed that the screws had been misplaced and were puncturing the patient's lumbar nerves. Accuracy of C2 pedicle screw placement using the anatomic freehand technique. Minimizing Pedicle Screw Pullout Risks: A Detailed Biomechan Facebook Google Plus Youtube RSS Email. 5. Although pedicle screw fixation opened a new horizon of spinal surgery by providing rigid fixation of the spine, it is a technically demanding procedure with potential complications including medical complications, hardware and technical problems, and long-term changes of junctional motion segments. Studdert DM, Mello MM, Sage WM, et al. 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. Schlegel JD, Smith JA, Schleusener RN: Lumbar motion segment pathology adjacent to thoracolumbar, lumbar, and lumbosacral fusions. Autor de la entrada Por ; Fecha de la entrada austin brown musician; matrix toners for bleached hair . The medicolegal landscape of spine surgery: how do surgeons fare? Spine 6:263267, 1981. Patient-specific 3D-printed surgical guides for pedicle screw insertion Pedicle Screw Malposition Expert Witness: Malposition Can Lead to Bethesda, MD 20894, Web Policies George Sapkas, MD, DSc; and Panayiotis J. Papagelopoulis, MD, DScGuest Editors. Gertzbein SD, Robbins SE: Accuracy of pedicular screw placement in vivo. 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? 36. Ultimately, no significant differences were seen in inflation-adjusted award information between plaintiff and defendant (Table 3). single homes for sale in lehigh valley, pa single homes for sale in lehigh valley, pa Home Realizacje i porady Bez kategorii single homes for sale in lehigh valley, pa Both issues represent the most frequent and highest payouts in spine malpractice claims.10,14,22 While several studies have explored many of the factors related to malpractice claims in spine surgery, the medicolegal impact of misplaced pedicle and/or lateral mass screws has not been directly reported in the literature. All case demographics are summarized in Table 1. 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 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. 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. Taylor CL. In the current series, including general complications, only 48 patients (43%) had no notable complication and the remaining 64 patients (57%) had one or more complications. Better strategies need to be devised for evaluation of screw placement, including establishment of a national database of deformity surgery, use of intra-operative image guidance, and reevaluation of postoperative low-dose CT imaging. Categorical and continuous data are described as frequency (percentage) and median (interquartile range), respectively, except for the use of mean standard deviation for award amounts since both nominal and inflation-adjusted award totals passed (alpha = 0.05) the DAgostino-Pearson omnibus normality test. Moffatt-Bruce SD, Ferdinand FD, Fann JI. Excessive hemorrhage occurred in two patients (1.8%) with coagulation disorders. A total of 2396 screws were placed accurately (87.96%). Malpractice issues in neurological surgery. Accuracy of fluoroscopically-assisted pedicle screw placement: analysis of 1,218 screws in 198 patients. Spine 17:349355, 1992. 34. Studies have shown that the greatest proportion of malpractice claims in spine surgery are related to procedural error,10,11,14,16,17,19 often resulting in the highest payouts.11,20 For spine surgery, one common area for the potential avoidance of malpractice claims and subsequent payouts involves misplaced pedicle and/or lateral mass screws, which occurs in approximately 14%55% of cases using standard techniques and results in neurological injury and/or durotomy in approximately 1%8% of cases.21 Misplaced screws have the potential to cause severe and sometimes permanent neurological deficits, including spinal cord and/or nerve root injury,21 as well as to decrease the stability of the fusion construct, leading to delayed complications related to pseudarthrosis.
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