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Right level, wrong site

01 September 2011

Mr G, a 40-year-old manager, saw Mr S, a spinal surgeon, in his consultation room with a short history of sciatica. Mr G presented with two weeks of back pain and pain radiating down the front of the left thigh to just below the knee. The pain was not responding well to NSAIDs, but no other treatments had been tried. Mr G was still working full-time, but his symptoms were interfering with his weekly squash match. He was having minor trouble sleeping.

In addition, Mr G was due to be best man at a friend’s wedding in two months’ time and was very keen to be fit for the nine-hour flight to the Caribbean.

On examination, there was no weakness but there was dulling to pinprick in the left anterior thigh. The knee reflex on the left was diminished but still present. Straight leg raising was normal but there was minor restriction to femoral stretch. An MRI was arranged and showed that the L4/L5 disc was prolapsed laterally. Mr S discussed surgery with Mr G but no other options for treatment were mentioned.

Mr G agreed to have the surgery and he was properly consented for the operation by Mr S himself. Although the surgery was uneventful, Mr G was thoroughly dissatisfied with the standards of nursing care he received and wrote a formal complaint. He felt that the nurses were abrupt and uncaring. He had to wait a long time for pain relief and was given no apology or explanation why.

Mr G’s symptoms persisted after the surgery and a new MRI showed that there was still a lateral disc protrusion compressing L4 root. Mr G made a claim against Mr S. Expert opinion was critical of the choice of surgical treatment in this case. The expert felt that Mr G’s symptoms were not severe enough, nor had they been present long enough, to consider surgery as a first option.

It was felt that a reasonable body of his peers would have suggested that conservative measures should have been tried first prior to consideration of surgery. In addition, Mr S’s surgical approach was incorrect for this particular patient’s unusual herniation. The far lateral component of the disc was unreachable through the usual medial fenestration approach. The case was settled for a moderate sum.

Learning points

  • Spinal surgery at the wrong level is, unfortunately, a fairly common error. This particular case is slightly more unusual since the level was right but the surgery was performed medially, not laterally, making it impossible to remove the offending disc fragment.
  • Familiarity with different surgical approaches to the spine is crucial so that the procedure can be tailored to the patient’s particular anatomical problem.
  • The indications for surgery should be the same, regardless of whether treatment is privately or publicly funded. Up to 80% of lumbar disc prolapses will resolve with conservative treatment. As a general rule, unless there are red flag signs (bladder involvement or weakness), many surgeons would allow a period of four to six weeks to pass to allow the disc prolapse to resolve spontaneously before considering surgery.1
  • It is important to take informed consent and explore all treatment options.
  • The risks and benefits of all possible treatments, including doing nothing, should be explained.
  • Be aware of the predisposing factors in claims, eg, poor communication and staff attitudes. This can cause patients to complain before anything goes wrong. Claims usually arise from a combination of predisposing and precipitating factors. Mr G was thoroughly dissatisfied with the care he received and so when his recovery from surgery was slow he was motivated to make a claim.

References

  1. Takada E, Takahashi M, Shimada K, “Natural History of lumbar disc hernia with radicular leg pain: Spontaneous MRI changes of the herniated mass and correlation with clinical outcome”, J Orthop Surg 9(1):1-7 (June 2001)
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