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Review
. 2025 May 15;19(1):16.
doi: 10.1186/s13037-025-00440-4.

From error to prevention of wrong-level spine surgery: a review

Affiliations
Review

From error to prevention of wrong-level spine surgery: a review

Parisa Javadnia et al. Patient Saf Surg. .

Abstract

Wrong-level spine surgery remains a significant concern in spine surgery, leading to devastating consequences for patients and healthcare systems alike. This comprehensive review aims to analyze the existing literature on wrong-level spine surgery in spine procedures, identifying key factors that contribute to these errors and exploring advanced strategies and technologies designed to prevent them. A systematic literature search was conducted across multiple databases, including PubMed, Scopus, EMBASE, and CINAHL. The selection criteria focused on preclinical and clinical studies that specifically addressed wrong site and wrong level surgeries in the context of spine surgery. The findings reveal a range of contributing factors to wrong-level spine surgeries, including communication failures, inadequate preoperative planning, and insufficient surgical protocols. The review emphasizes the critical role of innovative technologies-such as artificial intelligence, advanced imaging techniques, and surgical navigation systems-alongside established safety protocols like digital checklists and simulation training in enhancing surgical accuracy and preventing errors. In conclusion, integrating advanced technologies and systematic safety protocols is instrumental in reducing the incidence of wrong-level spine surgeries. This review underscores the importance of continuous education and the adoption of innovative solutions to foster a culture of safety and improve surgical outcomes. By addressing the multifaceted challenges associated with these errors, the field can work towards minimizing their occurrence and enhancing patient care.

Keywords: Safety protocols; Spine surgery; Surgical accuracy; Wrong-level spine surgery.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. Competing interests: The authors declare no competing interests. Consent for publication: Not applicable. Clinical trial number: Not applicable.

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