Sign, Mark & X-ray


Prevention of Wrong-Site Spinal Surgery

To help prevent wrong-site spinal surgery, NASS has developed the Sign, Mark & X-ray (SMaX) campaign. NASS encourages sharing of the campaign protocols and tools.

Sign, Mark & X-ray (SMaX) Campaign

Both wrong-site surgery (WSS) and wrong-site procedures (i.e., injections, interventional procedures) are recognized risks within spine care due to the repetitive nature of the anatomy and distortion of landmarks due to prior surgery or deformity. Since 2001, the NASS Sign, Mark and X-ray (SMaX) campaign has raised awareness and promoted prevention of WSS and procedures. The 2nd iteration of the technical document for the campaign was published in 2014, with prevention tools featuring a safety checklist for clinicians and take-home patient diagnosis diagram sheet to outline the site(s) of pathology to patients during office discussions. In 2023, an addendum was published providing updates to the SMaX campaign and its recommendations based on recent literature review.

Other Resources

View for additional information on prevention of wrong-site spinal surgery and procedures, including the Universal Protocol Poster from The Joint Commision - a global driver of quality improvement and patient safety in healthcare.