Patient Information Resources


Spine Institute
Glendale Adventist Medical Center
1500 E. Chevy Chase Drive, Suite 401B
Glendale, CA 91206
Ph: (818) 863-4444






Spine - Cervical
Spine - General
Spine - Lumbar
Spine - Thoracic

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I had a herniated disc removed at L34. Turns out they took the wrong one. How can this happen in today's modern world of technology? I had X-rays and MRIs done and they clearly showed where the problem was.

Choosing the wrong patient, wrong site, or wrong surgery is one of several mistakes that can occur in surgery. Doctors and hospitals have started to set up systems to help prevent these errors from occurring.

Three of these systems are called:

  • Sign Your Site (SYS)
  • Sign, Mark, and X-ray (SMaX)
  • Universal Protocol

    In all three systems, the surgeon uses a checklist to make sure nothing is forgotten. First the medical record is reviewed, and the patient is identified and confirmed. Then anatomy is reviewed to make sure the correct location or level is being operated on. Finally right before the first incision is made, the surgical team re-checks everything. Errors can be made if any of these steps are left out.

    For spinal surgery X-rays must be used in the operating room. A radiopaque marker is placed over the disc space to make sure the correct level is identified. The radiograph is reviewed against X-rays or MRIs taken earlier. Errors can be made when the electronic file or medical record isn't available in the operating room.

    Bony landmarks are used to help locate the correct level. The wrong level can be chosen if there are any unusual deformities or changes in the normal anatomy.

    Doctors do eveything they can to avoid mistakes but sometimes errors occur for any of these (and other) reasons.


  • References:

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