The Joint Commission Universal Protocol ¹ suggests that the spinal procedures surgical site mark be placed in the general skin area. The actual marking may vary, but the following guidelines can be used:

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  The mark should be unambiguous and consistent throughout the organization.

  
  
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  The American Academy of Orthopaedic Surgeons recommends including the provider’s initials ² .

  
  
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  We further suggest that the mark include procedural side with “L” or “R” and/or an accompanying arrow.

  
  
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  In the case of midline or bilateral procedures, such as interlaminar epidural steroid injections, include the side with the majority of the symptoms (e.g., Left > Right).

  
  
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  After skin preparation and draping, the mark should still be visible.

  
  
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  In Fig. 5.1 , the physician’s initials, the spinal level, and laterality are shown.

Marking the patient with correct procedure site, including physician’s initials, procedure, and laterality. Content of marking depends on local policy.

Confirming the details with the patient while site marking and confirming with skin preparation improves accuracy, eases patient anxiety, and improves perception of a safe environment.

Patient and all team members stop what they are doing and participate in the “time-out.” The patient verbally states his or her name and date of birth and confirms the procedure, side, and level.

A, Example of a visual cue whiteboard showing patient details, procedure followed, and other important patient variables. B, Example of a visual cue whiteboard (with identifying information) positioned alongside the fluoroscopy screen to assist with the patient time-out and constant intraprocedure confirmation. Having the whiteboard next to the fluoroscopy screen provides a real-time visual reminder to avoid a wrong-site or wrong-side procedure.

Put visual cues on a whiteboard that is placed in view throughout the procedure and in close proximity to the fluoroscope or ultrasound screen, to continually remind the interventionalist regarding the side, level, and type of procedure, as well as any other pertinent factors such as the following:

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  Allergies to medications typically used in procedures (contrast, antibiotic, anesthetic, latex, etc.)

  
  
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  More symptomatic side if bilateral or midline procedure is to be performed

  
  
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  Names of the physician performing the procedure, nurse present in the room, and referring physician (optional information)

However, one should avoid putting excess information on the whiteboard, as this may result in less emphasis on the information most vital to the procedure.

The C-arm should be set up so that it is easier to navigate once the procedure begins, with efficient adjustments made when needed ( Fig. 5.3A ).

A, Placement of C-arm in simulated patient. B, Zoomed in C-arm picture of the optimal piston starting setting (in neutral position). This allows the C-arm to be moved with ease for fine-tuning during the procedure (translation or pistoning of the image intensifier without complete lateral translation of the C-arm base). C, Suboptimal position of C-arm when starting procedure. Beginning at the extreme end of either of the positions causes excess movement of the C-arm during the procedure.

It is optimal for the pistoning (see Chapter 3 for further details on right/left, medial/lateral translation) to be set up in a neutral/midline position ( Fig. 5.3B ) once the target is identified.

It is suboptimal for the pistoning to be in any extreme position ( Fig. 5.3C ) since this makes fine-tuning more difficult.

Provides real-time recording of the heart rate, oxygen saturation, and other vital signs throughout the procedure.

May provide a level of comfort during the cervical spine procedures for patients positioned prone on a cervical board or supine with a sterile drape partially covering their face.

Blood pressure, rhythm and heart rate using electrocardiogram (ECG), and O ₂ saturation level should be monitored.

An additional dedicated nurse is needed to assist in monitoring vital signs and administration of pain-relieving and/or sedating medications.