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o the Editor:egarding the timely article by Goodkin and LaskaWrong Disc Space Level Surgery: Medicolegal Im-lications. Surg Neurol 2004;61:323–342), I wish tomphasize several points.

. If the spinal surgeon always obtains a good qual-ity plain spine X-ray showing the site of the op-erative intervention before leaving the operatingroom and verifies that with the preoperative in-tended level of surgery, then errors of wrong sitesurgery would be nearly eliminated. That mayrequire leaving a radiographic marker in place(such as a vascular clip), closing the wound andturning the patient from the lateral or someother position to the supine position. in thosecases if the radiographic marker is at the wronglevel, the patient has to be re-positioned and thewound re-opened. Although time consuming, theextra time and effort will likely be rewarding tothe patient and the surgeon. I have done that onseveral occasions in obese patients being oper-ated on for lumbar spinal stenosis in the lateralposition.

. If one does an operation at the incorrect level,recognizes the mistake and corrects it eventhrough the time-consuming manner mentionedabove before leaving the operation room andunder the same anesthesia, then one can argue,effectively I think, that it’s all one procedure andthat the surgery at the unintended level was anunfortunate complication and not a breach of thestandard of care. The chances are good that anumber of your colleagues will be willing to tes-tify on your behalf to that effect if you’re sued.However, if you find your error later, you’re go-ing to feel terribly alone.

. Difficulties with radiographic localization seemparticularly prone to occur when the patient iscorpulent or very muscular, when the patient ispositioned laterally or semi-laterally, when thethoracic spine is involved or when an image in-tensifier is used. In those cases, one sometimeshas to re-position the patient supine and/orbring in a portable unit to obtain a good qualityfilm.

. If you do make a mistake in the site of your

patient’s surgery, correct it as soon as you learn a

090-3019/04/$–see front matter

or your error and be forthright and honest withthe patient. Trying to cover it up will not workand will likely lead to even more serious legalconsequences than a negligence suit for wrongsite surgery.

. Your finger may not be the best way to find outwhere you are.

Howard Morgan, M.D.Professor

The University of TexasDallas, Texas

doi:10.1016/j.surneu.2004.04.018

esponse:e appreciate Dr. Howard Morgan’s comments and

is emphasis on the use of radio-opaque markerseft at the operated area that can be visualized withadiographs. As we noted in our discussion, radio-paque markers, such as silver clips, were fre-uently left affixed to paraspinal soft tissue at the

evel of surgery for postoperative confirmation.his technique has not been utilized by most sur-eons in the post-CT and MRI era, and it is no longeraught as a routine operative practice. However, ithould be considered by the surgeon when there isquestion regarding the level operated. This may

e a situation for the use of intra-operative CT orRI.Dr. Morgan also appears to share the opinion thatrong level disc surgery recognized and correctedt the time of the initial surgery is not a breach inhe standard of care.

We also thank him for emphasizing the otheroints that were discussed in our article.

Robert Goodkin, M.D.University of Washington Medical Center

Seattle, Washingtondoi:10.1016/j.surneu.2004.05.028

o the Editor:e have read with the greatest interest the article

y Escott et al (Proximal nerve root spinal heman-ioblastomas: presentation of three cases, MR ap-earance, and literature review. Surg Neurol004;61:262–73.)In the article, the authors have described 3 cases

f extramedulary hemangioblastomas nonassoci-

ted with von Hippel-Lindau (VHL) syndrome, and

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