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Dr. Schupeck,

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this is part two of a companion vignette in our

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57-year-old with low back pain,

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and originally had leg pain.

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They have operated on this patient,

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sagittal T2 with gentle fat suppression,

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sagittal T1 pre-contrast,

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sagittal T1 post-contrast.

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They clearly have operated on this level,

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which we'll call, for our purposes,

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5, 4, 3, 2, 1,

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L1-L2.

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But the pathology in vignette number one was at L2-L3,

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or what we would call L2-L3.

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So, they went one level up too high.

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Disaster.

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So how would you and somebody with a transitionalized

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amorphous morphology,

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how do you handle the counting scenario?

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What do you want? Yeah,

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the key is not what you decide to call something.

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It's being very clear about how you arrived at that

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and how you're describing it and leading

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them to the appropriate level.

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Meaning if you call it L5 or S1-S2,

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because you're going to see all sorts of things

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sacralization, unilaterally, bilaterally. Okay.

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Extra ribs, right? Extra ribs.

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I've seen like the worst lawsuit I ever

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saw was somebody had 13 ribs,

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and I've seen up to 15 ribs, I think.

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So it's really easy to get messed up.

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So the key is being very clear about what you did.

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What I'll do is look at the scan and say, okay,

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on the axial images, what's the lowest, actually,

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image disk space? Okay.

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Because they can figure that out.

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And then I'll say, okay, what am I going to call that?

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And then I'll give that a name.

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I'll say the lowest axial image disk space

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is designated as L5,

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S1 or whatever for the purposes of this report.

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Okay?

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And then I'll say the next level above this looks like

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this. It's a normal AP diameter, normal height,

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has a big spur, whatever,

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and is the level of predominant pathology.

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Okay.

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And I'll try to highlight that and put all the

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other anatomic landmarks so what you call it,

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I don't like to use 56 very much because then

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which route is calling? Which route?

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That's confusing. Is confusing.

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But you could but as long as you're clear about

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what you're doing, they can read it.

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And you're consistent among reports.

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You got to look at the old reports because they're

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going off that they've already formed a determination

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in their own mind what level they're looking.

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You better make sure you're consistent

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with old reports.

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And if you're not awake for this part of the vignette,

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you're in big trouble. Right.

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And this person who did the operation is in some

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trouble. The patient is in some trouble.

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Now,

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there are a couple of other highlights in this case,

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one of which is,

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if you look at the cases of Arachnoiditis that

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we showed, you get this very corkscrew,

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clump-looking appearance of the nerve roots, which,

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by the way, is very common, usually in.

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The absence of arachnoiditis with canal stenosis,

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but you can get both of them coexisting together.

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Usually when they do,

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there's less CSF interspersed between the roots.

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They're more aggregated.

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Now you can see how tight things are

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at the unoperated L2 level,

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which should have been the one that was originally

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approached, you can see some susceptibility effects,

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some enhanced, and some granulation tissue.

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They really opened up this level.

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Unfortunately, the wrong level. Yeah.

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One other thing. What do you do when you see this?

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That is, you look back and you say, wow,

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they said they did this level,

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but they actually did this one.

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Then what do you write on the report?

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Conclusion number one wrong level surgery.

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No. Okay,

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so what I did was I called the doctor and I said,

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he's in the OR. He's a busy guy,

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and can you take a look at this case?

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And he takes a look at it and calls me back,

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and we have a discussion about it because

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the patient may see the report before he does.

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Okay? So we got to be in agreement with the doctor.

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He knows what happened.

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He knows what he's going to do.

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He wants to present it to the patient in a way,

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telling them what happened. But also, okay,

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here's what we go from here.

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How could this kind of thing happen?

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You want to think through these things with them.

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So the first thing is a phone call.

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Phone call, and then, say,

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helping him think through the problem,

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what he's going to do?

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So that when he's ready, when the patient does,

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he will have to tell the patient about it.

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Need another operation or her.

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Correct.

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That is a big part of it.

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Because I'll tell you, wrong level surgery,

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particularly if they think that you weren't clear,

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is where you lose more friends between surgeons and

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radiologists. So it is the number one issue.

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If you're in the right place with the wrong pathology,

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you can still usually work it out.

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If you're in the wrong place, no way.

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These days, it's just not an acceptable era.

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I've been Chief of Staff,

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at the best hospitals in the world.

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You'd recognize all the names that I've had the

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opportunity to be at. It happens everywhere.

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It's just not that hard.

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I mean, I had to go through seven different counts.

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Every time I did a case in the OR,

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I had people put these big feet where I was supposed

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to stand on the proper side of the table.

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You drive people nuts. It took, like, 20 minutes.

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But if you don't do that I've gotten the number

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five of this thing and been wrong.

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But the bottom line is anatomy, narrative,

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visible structures on an X-ray, in an AP,

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in the lateral and consistency.

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Looking at the old report,

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none of these algorithms that they have in the

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OR of preventing wrong level surgery work.

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And the reason is, if the surgeon's wrong.

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He's going to make everybody else wrong.

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So what you have to do is write your report in a way

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that you help this make the surgeon think like.

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Oh, wait a second. There's a level problem here.

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The radiologist went to great lengths to identify the

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level because he thought I could have a mistake.

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So once the surgeon's thinking,

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then that can salvage it.

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The scrub nurses, stuff like that, they just can't,

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because they do whatever the surgeon is going to tell.

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I love the idea of surgeons thinking,

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especially if I'm the patient.

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Let's move on to case number three or companion van.

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Get number three, see where thinking occurred,

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but the outcome wasn't so good.

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Let's look at that.