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Managing patient expectations

01 May 2013

Mr G was admitted to hospital under Mr R, consultant orthopaedic surgeon, complaining of severe right leg pain. Mr G had a long history of back pain and had already undergone a disc removal at L5/S1 some years earlier. On this occasion, Mr G was complaining of severe back pain and radiating pain down the right leg for about two weeks. His pain was very severe and he was unable to work.

An MRI scan was obtained, which showed a large recurrent disc prolapse at L5/S1 with a retrolisthesis and end plate oedema at that level. In hospital, conservative treatment was begun, but after five days there was no improvement.

Mr R suggested a revisional discectomy and pedicle screw fusion at L5/S1. He carefully explained and documented the uncertainty about the results of such surgery and the increased risks because of the previous procedure at that level. Mr G wished to go ahead.

Following surgery, Mr G was still in a lot of pain. A CT scan was performed, which showed that the right sided pedicle screws were too long and had protruded beyond the front walls of both the L5 and S1 vertebrae. The tips of the screws were reasonably close to the iliac artery and vein. However, there was no evidence of intra-abdominal injury or haematoma.

Because Mr G’s pain was continuing, a further operation was performed and the screws were replaced. During surgery, the bone at S1 was found to be osteoporotic and an oversized screw was required to gain purchase. Mr G improved for a few days but then his pain returned and continued unabated. Further scanning showed no complications.

Mr G was dissatisfied and began a claim against Mr R. He felt that Mr R had not examined him properly and had failed to discuss the problems that could be caused by a weak vertebra, or the nerve damage that could result.

Expert opinion found that Mr R had adequately explained all the risks of the operation, and had tried a reasonable period of conservative treatment before surgery was undertaken. The inappropriate initial placement of the pedicle screws on the right was unfortunate, but there was no evidence that this had injured the patient.

Expert opinion also found that the manipulation of the L5 roots at the initial surgery was the cause of the continuing pain, but this can occur in the best of circumstances and did not constitute negligence. There was no way to predict the osteoporotic nature of the S1 vertebra preoperatively. A detailed letter of response was sent and the claim was successfully defended.

Learning points

  • Patient expectations must be carefully managed. Under ideal conditions, lumbar surgery has an approximate 80% success rate. In situations such as this case, where there has been previous surgery and instrumented procedures are contemplated, the overall results may not be quite that good. Patients must always be informed of these facts and of the risks to neurological structures, and this must be well documented.
  • A failure to resolve the patient’s symptoms does not constitute negligence.
  • When proposing surgery on the spine for benign conditions, it is important to first explore the possible benefit of non-surgical treatments. Very rarely is surgery appropriate as the first line of treatment.
  • Sometimes things happen during surgery that are less than ideal, such as in this case, where pedicle screws were used that were too long. Although these screw placements were inappropriate, no harm occurred as a result, and so a claim of negligence was unsuccessful.