Right level, wrong site (1)
I read the September 2011 Casebook with interest, specifically the report on “Right level, wrong site” (p21). I know of more than one surgeon who believes that all lumbar disc lesions can be approached surgically from the midline!
That is unequivocally untrue as your expert so rightly pointed out. One of my points comes from your section on learning points in relation to the management of acute lumbar disc lesions. In the lumbar spine the spontaneous resolution rate for acute disc protrusions is closer to 100% than 80%, but specifically time-related.
Sadly the world literature is badly biased by the fact that surgeons tend to advocate surgery and it is not in their interest to be promoting conservative management: a cynical but truthful observation. Patients should be advised that the outcome of conservative versus operative treatment is little if no different at 12 to 18 months. Surgery offers the advantage of a short cut but risks not insignificant complications; conservative management has minimal risk but often a drawn-out recovery. Extraordinarily I have read notes that record that patients with lumbar disc lesions will not get better without surgery!
In relation to the time allowed for spontaneous resolution of these lumbar disc lesions, four to six weeks is, I have to say, an exceptionally short period of time to suggest before considering surgery. Certainly there will be occasions, short of cauda equina compression, where in special circumstances early surgery may be considered – but the message that MPS supports such early surgery may not be a good one to be promulgating.
Surgeons tend to advocate surgery and it is not in their interest to be promoting conservative management: a cynical but truthful observation
I know that the difference between private and public treatment standards in respect of surgical advice exists and I am pleased that you raised that, to try to keep practitioners honest in that respect.
Another interesting point arises in relation to communication. Doctors (surgeons) can be quite foolish on occasions by telling patients that a particular treatment previously given to their patient was wrong simply because it was not their own practice. This is particularly important now that the ‘school of opinion’ defence has been challenged. Doctors should be taught and reminded that they must resist the temptation to portray themselves as the saviour of a situation by denigrating previous unsuccessful but perfectly proper treatment.
As an orthopaedic spinal who performed more than 7,000 open spinal operations, I do speak from a depth of experience. One final point in the form of a question. Are surgical trainees and newly-appointed consultant surgeons being formally and appropriately (not voluntarily) appraised of their responsibilities in relation to medical insurance? It would be difficult if not impossible to argue against mandatory malpractice education as a requirement for medical insurance!
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