Case Study: Wrong-Level Spinal Surgery Resulting In Irreparable Damage

The Price of a Mistake:

How a “Wrong-Level” Surgery Changed One Woman’s Life Forever

Imagine walking into a hospital with the hope of finally ending years of radiating neck pain, only to wake up to a nightmare far worse than the one you sought to escape. This is the story of “Jane,” a dedicated mother, wife, and the primary breadwinner for her family, who fell victim to one of the most preventable errors in modern medicine: wrong-site surgery.

As a star car salesperson at one of the region’s top dealerships, Jane was known for her infectious energy, her ability to connect with customers, and her relentless work ethic. She regularly topped the sales charts, working long hours on the showroom floor to provide for her children and build a secure future for her family. But when a surgical error at a major medical center left her with permanent nerve damage and a fused spine far more extensive than she ever required, her world—and her family’s security—collapsed in an instant.

Understanding the Medical Crisis: The Delicate Architecture of the Cervical Spine

To understand the magnitude of what happened to Jane, you must first understand the intricate and delicate architecture of the human neck, or cervical spine.

The cervical spine consists of seven vertebrae, numbered C1 through C7 from top to bottom. Between each vertebra sits a cushioning disc that allows the neck to move while protecting the spinal cord. When one of these discs herniates—meaning it bulges or ruptures—it can press against nearby nerves, causing excruciating pain, weakness, numbness, and tingling that radiates down the arms.

Jane suffered from a herniated disc at the C6-C7 level—the junction between the sixth and seventh cervical vertebrae. This damaged disc was compressing her nerves, causing debilitating weakness and “pins and needles” sensations that shot down both arms. After exhausting conservative treatments like physical therapy and pain medication, her doctors recommended surgery.

The solution was supposed to be straightforward: an Anterior Cervical Discectomy and Fusion (ACDF). In this common procedure, the surgeon approaches the spine through the front of the neck, removes the damaged disc, and fuses the two adjacent vertebrae together using bone graft and hardware to stabilize the spine. When performed correctly at the proper level, ACDF has excellent outcomes and can restore patients to active, pain-free lives.

But Jane’s case would be anything but straightforward.

The First Red Flag: A Troubling Documentation Error

The cascade of errors began long before the first incision was made. Despite crystal-clear MRI results showing the herniated disc was at C6-C7, the surgeon’s pre-operative documentation told a different story. He mistakenly recorded that he would be operating on the C5-C6 level—an entirely different segment of Jane’s spine.

This wasn’t a minor typo. This was a fundamental misidentification of the surgical target that should have been caught through multiple safety checkpoints: the pre-operative review, the surgical consent process, the time-out protocol in the operating room, and the intraoperative verification using imaging. Each of these safeguards exists precisely to prevent wrong-site surgery.

They all failed.

A Tale of Two Surgeries: When “Anatomic Anomalies” Become Excuses

The nightmare began on May 13, 2021. Jane arrived at the hospital nervous but hopeful. She kissed her children goodbye that morning, promising them she’d be home soon and that the pain that had stolen so much of her vitality would finally be gone.

The surgeon attempted the anterior approach—coming through the front of her neck to access the spine. But partway through the procedure, he abruptly stopped. He claimed he encountered “anatomic anomalies” that made it impossible to continue safely, and he closed the incision without completing the fusion.

Jane woke up confused and still in pain. The surgeon assured her this was a temporary setback and that they would try again using a different approach.

Expert review later revealed the devastating truth: these “anatomic anomalies” the surgeon cited were nothing more than routine connective tissue and muscle that any competent spine surgeon should have been able to navigate without difficulty. The aborted surgery was likely the result of inadequate surgical technique, not unusual anatomy.

One week later, on May 20, 2021, the surgeon tried again—this time using a posterior approach, entering through the back of Jane’s neck. But the documentation error was now carved in stone. Following his mistaken pre-operative plan, he operated on the C5-C6 level—a completely healthy segment of Jane’s spine that had never caused her any symptoms.

The disc that was actually causing her pain, at C6-C7, remained untouched.

“There is absolutely no reason and no justification in the medical record for the performance of that procedure at C5-6. The patient’s symptoms, imaging findings, and clinical presentation all pointed to C6-7. This is a clear and indefensible deviation from the standard of care.” — Expert Orthopedic Surgeon Review

The Aftermath: A Mother’s Agony

Jane woke from the second surgery in agony that defied description. This wasn’t the expected post-surgical discomfort that would gradually improve. This was a new, vicious pain that radiated through her neck, shoulders, and arms in ways she’d never experienced before.

The “success” the surgeon reported in his operative notes didn’t match the reality Jane was living. Her original symptoms hadn’t improved because the actual problem had never been addressed. But now she had new problems: muscle spasms so severe that she couldn’t brush her teeth without her neck muscles seizing in violent, involuntary contractions.

Her family watched in horror as the woman who had once spent 10-12 hours on her feet at the dealership, radiating confidence as she closed sale after sale, was now doubled over in pain, unable to perform the simplest daily tasks. She couldn’t pick up her brief case. She couldn’t turn her head to check her blind spot while driving. She couldn’t sleep more than a few hours without being jolted awake by muscle cramps.

For Jane, the emotional devastation matched the physical torture. She had been her family’s rock, their primary financial provider. Now she was dependent on them for help with basic activities. The guilt she felt was almost worse than the pain.

Demanding Answers: When Something Doesn’t Add Up

Jane’s husband knew something was catastrophically wrong. His wife had gone in for a routine surgery and come out worse than before—much worse. When he pressed the surgeon for explanations, he received only vague reassurances that “sometimes these things take time to heal” and that additional procedures might be needed.

Frustrated and frightened, the family began asking more pointed questions. They requested copies of all medical records. They sought second opinions from other spine specialists. And what they learned made their blood run cold.

A consulting neurosurgeon reviewed Jane’s post-operative imaging and delivered shocking news: the surgery had been performed at the wrong level. The herniated disc that had been causing all of Jane’s original symptoms was still there, still pressing on her nerves. Meanwhile, a perfectly healthy level of her spine had been unnecessarily fused.

Shortly after this discovery, a letter arrived from the hospital’s Patient Safety Director—a rare and startling document known as a “letter of admission.” In carefully worded legal language, the hospital acknowledged what had happened: their surgical team had operated on the wrong level of Jane’s cervical spine.

It was an admission of one of medicine’s most serious “never events”—errors so egregious and preventable that they should never occur under any circumstances.

Turning to Lupetin & Unatin: The Search for Justice and Truth

Devastated and betrayed, Jane and her husband knew they needed help navigating the complex intersection of medicine and law. They needed more than just a lawyer—they needed a legal team with the medical expertise, resources, and tenacity to take on a major medical institution and hold them accountable.

They turned to Lupetin & Unatin.

From our very first meeting, we knew this case represented everything wrong with how some medical institutions respond to their own errors: initial denial, vague explanations, and only grudging admissions when confronted with undeniable evidence. We also knew that Jane’s story needed to be told, and that her family deserved not just answers, but justice.

Our investigation began immediately and was exhaustive in scope.

Reconstructing the Timeline of Negligence

We obtained every page of Jane’s medical records—thousands of pages spanning her initial consultations, MRI reports, surgical consent forms, operative notes, nursing records, and post-operative care documentation. We created a minute-by-minute timeline of the care she received, identifying every point where the error could have been caught and corrected.

What we discovered was a systemic failure at multiple levels:

• The pre-operative imaging clearly showed pathology at C6-C7
• The radiologist’s report explicitly identified C6-C7 as the problem level
• The surgeon’s documentation mistakenly identified C5-C6 as the target
• The surgical consent form listed the wrong level
• The intraoperative “time-out” safety protocol failed to catch the discrepancy
• Post-operative imaging was not immediately reviewed to confirm proper level

Each of these was a missed opportunity to prevent the catastrophic outcome that followed.

Assembling World-Class Medical Experts

Medical malpractice cases live or die on expert testimony. We knew we needed the very best.

We retained an Associate Professor of Orthopedic Surgery from a prestigious university medical center—a nationally recognized spine surgeon who had performed thousands of cervical fusion procedures and who taught other surgeons proper technique. His review was damning:

“The failure to correctly identify the pathological level despite clear imaging is a grave error that represents a fundamental breach of the standard of care. The decision to proceed with fusion at C5-6, a level with no demonstrated pathology, cannot be justified under any circumstance. This wrong-level surgery directly caused the patient’s need for additional procedures and has resulted in a significantly worse outcome than if the correct level had been addressed initially.”

We also consulted with pain management specialists, life-care planners, and vocational experts to fully document the scope of Jane’s injuries and their impact on every aspect of her life.

Quantifying a Lifetime of Damage

The physical injuries were obvious, but we needed to quantify the full economic and human cost of this error. We hired certified life-care planners to project Jane’s future medical needs over her expected lifespan:

• Additional surgeries: Jane would need at least two more cervical fusion procedures—one to finally address the original C6-C7 herniation, and another to manage “adjacent segment disease” (accelerated degeneration of the spine levels above and below a fusion)
• Pain management: Ongoing Botox injections for severe muscle spasms, epidural steroid injections, nerve blocks, and pain medication
• Physical therapy: Regular sessions to maintain mobility and strength
• Medical equipment: Cervical collars, TENS units, ergonomic modifications to her home
• Lost earning capacity: Jane’s career as a top-performing salesperson was over; she would never again be able to work the long hours on her feet that had made her so successful

The total projected cost of future medical care alone exceeded $2.5 million.

But numbers don’t capture the human cost: the mother who couldn’t play with her children, the wife whose chronic pain strained her marriage, the breadwinner who felt she had failed her family, the vibrant woman whose identity had been built around her energy and work ethic, now forced to ask for help with basic tasks.

Proving the Case: The Elements of Medical Malpractice

To win Jane’s case, we had to prove four critical legal elements beyond mere medical error:

Duty of Care

The surgeon and hospital owed Jane a duty to provide care that met the accepted standard within the medical community. This duty was established the moment Jane became their patient and consented to surgery.

Breach of Duty

By operating on the wrong level of her cervical spine—a level that was healthy and caused her no symptoms—the surgeon and hospital failed to meet this standard of care. Our expert testimony made this clear: no reasonable spine surgeon, acting with appropriate care and skill, would have made this error given the clear imaging and clinical findings.

Causation

The wrong-level surgery directly caused Jane’s new injuries. This wasn’t just a bad outcome from an appropriate procedure; this was an entirely inappropriate procedure that created new pathology. Because the surgeon fused C5-6 instead of addressing C6-7, Jane required a third “rescue” surgery to correct the error, resulting in a massive fusion from C4 to C7—far more extensive than she ever needed.

This extensive fusion created what spine surgeons call “adjacent segment disease”—the levels above and below a fusion experience increased stress and degenerate faster, leading to additional pain and the likely need for future surgeries.

Damages

Jane suffered catastrophic, quantifiable losses—both economic and non-economic:

• Economic damages: Medical expenses exceeding $2.5 million, lost wages from her high-earning sales career, lost earning capacity for the remainder of her work life
• Non-economic damages: Chronic pain and suffering, loss of enjoyment of life, emotional distress, inability to perform activities of daily living, loss of her identity as a provider and active mother

The Push to Trial: Maximizing Justice for Our Client

As we approached trial, we made it clear to the defense that we were fully prepared to present Jane’s story to a jury. We had retained animation experts to create visual presentations showing exactly what happened to Jane’s spine. We prepared Jane to testify about her daily struggles. We lined up her family members to describe watching her deterioration.

The defense knew what we knew: a jury would be outraged by this case.

Wrong-site surgery is the kind of medical error that ordinary people instinctively understand is inexcusable. It’s not a matter of complex medical judgment or competing treatment philosophies. It’s operating on the wrong body part—a “never event” that violates the most basic principle of surgery: first, do no harm.

We pushed the case to the very edge of jury selection. Our trial notebooks were prepared. Our witnesses were ready. Our opening statement would show the jury the x-rays of the unnecessary hardware bolted into Jane’s spine at the wrong level, while the actual problem went unaddressed.

Facing the overwhelming evidence we had marshale the defendants agreed to enter serious settlement negotiations.

The Outcome: A Multi-Million Dollar Settlement

After intense negotiations conducted literally on the courthouse steps as we prepared for trial, we secured a multi-million dollar settlement for Jane and her family.

The exact terms are confidential, but the settlement provided:

• Full compensation for all past and future medical expenses, including the additional surgeries Jane will inevitably need
• Replacement of her lost earning capacity from her career as a top-performing car salesperson
• Substantial compensation for pain and suffering, both past and future
• Financial security for her children’s education, ensuring her sacrifice wouldn’t derail their futures

A New Chapter: Life After Settlement

While no amount of money can restore Jane’s health or take away the chronic pain she feels every morning when she wakes, this settlement provided a different kind of healing—the healing that comes from justice, accountability, and financial security.

Retirement with Dignity

Jane was able to retire from the high-pressure car sales job she loved but could no longer physically perform. The long hours on her feet, the constant movement around the showroom, the physical demands of test drives—all of it was now impossible. But thanks to the settlement, she could retire without financial devastation, preserving her dignity and her family’s standard of living.

Securing Her Children’s Futures

As a mother, one of Jane’s greatest sources of guilt was the fear that her medical crisis would derail her children’s futures. The settlement allowed her to fully fund their college educations, ensuring that her injury wouldn’t limit their opportunities. Her children would have the futures she had worked so hard to provide—even though she could no longer work herself.

Lifetime Medical Care

Perhaps most importantly, the settlement covers the specialized medical care Jane will need for the rest of her life. The additional fusion surgeries that will almost certainly be necessary. The Botox injections that help control her muscle spasms. The pain management treatments that make her daily life bearable. The physical therapy that helps maintain her mobility.

She doesn’t have to choose between getting the care she needs and paying her bills. She doesn’t have to suffer in silence because treatment is too expensive.

The Emotional Resolution

Beyond the financial aspects, the settlement represented something equally important: acknowledgment. After the initial denials and vague explanations, the substantial settlement was an admission that what happened to Jane should never have happened. That she deserved better. That the system failed her.

For Jane and her family, that acknowledgment mattered almost as much as the financial security.

Why This Case Matters: Holding Medicine Accountable

Jane’s story is a powerful reminder that when the medical system fails, the civil justice system is the only tool powerful enough to hold it accountable.

Wrong-site surgery continues to occur in hospitals across America despite decades of safety initiatives and protocols specifically designed to prevent it. The National Quality Forum lists wrong-site surgery as a “Serious Reportable Event”—an error so grievous that it should never happen. The Joint Commission requires a “Universal Protocol” that includes pre-operative verification, site marking, and a formal time-out before incision.

Yet these errors persist because systems fail, humans make mistakes, and sometimes—as in Jane’s case—multiple safety nets fail simultaneously.

When that happens, injured patients need experienced legal advocates who understand both the medicine and the law, who have the resources to take on major medical institutions, and who have the tenacity to push cases to trial when justice demands it.

The Legacy of a Fighter

Before her injury, Jane was known as a star—a top performer who could outsell anyone on the showroom floor through sheer determination and connection with her customers. After her injury, she showed that same fighting spirit in pursuing justice against a hospital that failed her.

She didn’t accept vague explanations. She demanded accountability. She fought for her family’s future even while struggling with chronic pain. And through her courage and our partnership, she ensured that her family would still shine, even after the lights in the showroom went dark forever.

If you or a loved one has suffered from wrong-site surgery or any form of medical malpractice, the attorneys at Lupetin & Unatin have the experience, resources, and commitment to fight for the justice you deserve. We don’t just handle cases—we become partners with our clients in their fight for accountability and fair compensation.

This case study is based on an actual matter handled by Lupetin & Unatin, LLC. Names and identifying details have been changed to protect the confidentiality of the settlement and the privacy of the parties involved. The settlement amount reflects the resolution of this particular case and is not a guarantee of results in any other matter.