Anatomy of a claim
In Casebook 22(1), January 2014, the feature “Anatomy of a claim” tells a depressingly familiar story.
Frequently and incorrectly termed “discitis”, infections of the vertebral bodies are commonly missed clinically. The vascular anatomy in the juxta-discal area shows a pattern of end vessels throughout life – hence a vulnerability to infection. The disc is avascular and infection can only occur by direct innoculation, eg, during surgery or discography.
In cases of thoracic spinal infection and in my experience of more than 35 years as a spinal surgeon, careful clinical examination of the spine will invariably disclose clear evidence. Pain and tenderness on local pressure will always be associated with the back pain history. Chest pain or radicular pain may also be present. The ESR is invariably raised.
Given the typical history given by Mr P, Dr C’s conclusion that the symptoms represented “muscular back pain” was made on the basis of symptoms that must have been present for more than ten days’ duration, and this was Mr P’s third consultation. Events showed this to be a serious misjudgment. Dr A’s second consultation (Mr P’s fourth) 25 days after his original assessment, with an increase in symptomatology and in the absence of a diagnosis, resulted in an entirely inappropriate referral for physiotherapy. This treatment is likely to have caused the onset of neurological symptoms six days later.
The subsequent surgical investigation and operative treatment was both inappropriate and negligent, and therein lay the liability and causation
Mr P was noted to have a loss of sensation in his legs at the time of hospital admission. An MRI scan undertaken at another hospital disclosed an “infective discitis at T5-6”. Two laminectomies were undertaken, following which Mr P was rendered paraplegic. Laminectomy has been recognised as contraindicated as a surgical procedure for infections of the thoracic vertebral bodies for over 100 years. The history indicates that the laminectomy directly resulted in the complete spinal cord injury in Mr P at T4 (at least one level higher than the bony pathology). If the indication for surgery existed, a closed biopsy followed by an anterior debridement via a thoracotomy or an approach via a costo-transversectomy should have been undertaken. A majority of cases can be managed by appropriate antibiotic treatment.
If Mr P’s legal advisers had instructed experts who were familiar with the presentation and appropriate treatment of spinal infections, the outcome would have been very different. On the basis of the history, the claim that Drs A and C failed to suspect a spinal infection or arrange correct investigation that should have necessitated an urgent referral meant that Mr P’s claim is self-evidently correct. This was a failure of duty of care. The subsequent surgical investigation and operative treatment was both inappropriate and negligent, and therein lay the liability and causation. This should have been recognised by Drs D, E and G, and Mr F, had they been familiar with the extensive surgical literature on the subject.1
With correct clinical management, Mr P’s catastrophic outcome was avoidable. The case may represent a satisfactory outcome for MPS but it also represents a grossly unfair outcome for the patient/claimant.
Alistair G Thompson
Consultant Orthopaedic Spinal Surgeon, Birmingham, UK
- Bridwell KH and De Walt RL (eds), Textbook of Spinal Surgery (2nd Edition), Philadelphia: Lippincott-Raven (1997)
Thank you for your comments on this article. In this case it is important to note that in this case the claimant did not bring any allegations in respect of the surgical treatment provided. The allegations were in respect of Drs A, B and C who saw Mr P at the GP surgery.
At trial it was clear that Mr P had no real recollection of what he had told the GPs about his symptoms during the various consultations
In accordance with the general principles of medical negligence, the standard on which the three doctors are judged is that of the reasonable general practitioners. On the doctors’ account of the case the GP expert evidence was supportive. Although there was a potential conflict of factual evidence (ie, what actually happened in the consultations), at trial it was clear that Mr P had no real recollection of what he had told the GPs about his symptoms during the various consultations.
Whilst an assessment at the beginning of the process by a specialist might potentially have resulted in an earlier diagnosis (depending on what symptoms were actually present), the standard to be applied is that of the reasonable GP, and our expert was clear that doctors A, B and C had reached that standard.
The question of adequate consent and the preoperative discussion of possible risks and complications frequently appear in Casebook. Are there any templates of consent forms available for gynaecological procedures (especially laparoscopic procedures)? Is it not something that MPS should be involved in creating or developing?
Dr AA Carolissen
Gynaecologist, South Africa
Thank you for your observations and comments. MPS does not produce specific templates or forms for use in the consent process. Consent is a process that will vary depending on the circumstances. Although there are some specific exceptions in relation to certain procedures, interventions and circumstances (eg, sterilisation and termination of pregnancy, which require the completion of statutory forms), the actual format of the consent is less important than the accurate documentation of the process. MPS has produced a comprehensive guide – Consent to Medical Treatment in South Africa – which is available on our website.