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Operate or wait?

01 August 2005

Mr E had developed a bad back and a friend had recommended that he see Mr G, an orthopaedic specialist. Mr E made an appointment to see Mr G at a private hospital in the UK without asking his GP to refer him. Mr G thought that Mr E had a prolapsed lumbar disc, which he treated with epidural and facet-joint injections. An MRI scan confirmed a small left-sided paracentral disc prolapse, pressing on the L3/4 nerve root.

A few days later, Mr G performed a laminectomy. Mr E’s symptoms didn’t settle and a repeat MRI scan showed sequestrated disc prolapse at L3/4, indenting the theca and with some surrounding haematoma. Six weeks after the original surgery, Mr G re-explored the L3/4 area, excised a disc fragment and drained the haematoma.

Mr E did not do well; he continued to struggle with severe lower back pain and spasm and was fitted with a plaster jacket but had great trouble getting about. There are only nursing notes available for this period. A lumbar radiculogram showed only swelling of the L3/4 nerve root.

A fortnight later, Mr G performed an L3/4 fusion procedure using an iliac crest autograft. There are no notes of either the clinical findings or decision-making processes that led to this course of action. The operation note states, ‘no disc, some adhesions – only instability’. 
The next day, Mr E became acutely unwell, having suffered a pulmonary embolus. He was transferred to a public hospital under the care of a physician and anticoagulated. He began to recover from his embolus but, after a few days, developed signs of cord compression.

An MRI scan revealed a large extradural haematoma at the previous surgical site, which was evacuated by another orthopaedic specialist, after reversal of the anticoagulation. Mr E made a good recovery and, after some initial disturbance of his sphincter function, which settled, he was able to mobilise fully. He was left with significant sensory disturbance in his lower limbs and absent ankle jerks bilaterally.

Mr E started legal proceedings against Mr G, alleging that he was negligent in operating so early in the natural course of his prolapsed disc, and that the immobilisation caused by overzealous surgical management resulted in the pulmonary embolus, and thus the cord compression.

Expert opinion

Orthopaedic expert opinion did agree that it could be argued that the operation had been carried out too soon. In the absence of detailed notes clarifying Mr G’s clinical thought processes, it was decided that the case would be very difficult to defend.

We paid Mr E a sum equivalent to £250,000 as compensation for his suffering and subsequent disability.

Learning points

  • Documentation – Before carrying out an invasive procedure, it is important to document your decision making – ie why, in your opinion, the surgery is needed and the clinical features that support your opinion. Otherwise, if there is an adverse outcome, your position will be difficult to defend. An excellent overview tutorial on the clinical features of lumbar disc prolapse is available here.
  • Accepting referrals – In the UK it is professionally discourteous and potentially dangerous to treat patients without the knowledge of their GP. If a patient self-refers, and it appears that his/her GP is not aware that they are being treated, ensure that they are informed, with the patient’s consent.