Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity

Michael Vitale, Anas Minkara, Hiroko Matsumoto, Todd Albert, Richard Anderson, Peter Angevine, Aaron Buckland, Samuel Cho, Matthew Cunningham, Thomas Errico, Charla Fischer, Han Jo Kim, Ronald Lehman, Baron Lonner, Peter Passias, Themistocles Protopsaltis, Frank Schwab, Lawrence Lenke

Research output: Contribution to journalArticlepeer-review

18 Scopus citations


Study Design: Consensus-building using the Delphi and nominal group technique. Objective: To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. Summary of Background Data: Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. Methods: The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. Results: Participants had a mean of 13.4 years of practice (range: 2–32 years) and 103.1 (range: 50–250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. Conclusion: We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. Level of Evidence: Level V.

Original languageEnglish
Pages (from-to)121-129
Number of pages9
JournalSpine Deformity
Issue number2
StatePublished - 1 Mar 2018


  • Best practice guidelines
  • Delphi process
  • Spinal deformity
  • Wrong level surgery


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