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At a different level

01 January 2008

Mr G was a 41-year-old accountant and a keen cyclist. He visited his GP, Dr M, because he was suffering from worsening lumbar back and left-leg pain and occasional numbness in his left foot.

After numerous appointments with Dr M and several failed physiotherapy manipulations, Mr G was referred to a consultant neurosurgeon, Mr L. By this time, Mr G was unable to walk for longer than half an hour at a time, despite regular diclofenac and co-codamol. He had been taking more and more days off work. Mr L arranged an MRI scan which showed a prolapsed disc at L4- L5, suitable for microdiscectomy and lumbar laminectomy. A slight prolapse at L3-L4 was also visible on the scan. Mr L accepted Mr G on to his busy waiting list.

Several months later, on the day of Mr G’s surgery, Mr L obtained consent and answered Mr G’s questions.

Mr G was given his general anaesthetic and Mr L prepared to commence the procedure. Mr L was soon informed that the image intensifier was not working. Mr L decided to continue without the image intensifier insisting he could identify the correct site clinically.

After the operation, the wound on Mr G’s back was sore and uncomfortable when he turned in bed and he could still feel his original pain. When he attempted getting out of bed he noticed his left leg was weak and numb and he experienced faecal incontinence.

An MRI showed a haematoma to have caused cauda equina syndrome and it also showed that the lumbar laminectomy had been carried out at L3-L4 and the prolapsed L4-L5 disc remained.

Mr G was taken back to theatre and operated on by a second neurosurgeon, Mr W. Here, the haematoma was removed and the correct microdiscectomy and lumbar laminectomy at L4-L5 was performed.

Mr G was left with pain and a significant permanent neurological deficit. He was unable to return to full time work despite physiotherapy and medical treatments.

Mr G brought a claim against Mr L for operating at the wrong level, markedly worsening his problems and leaving him incontinent and impotent.

Expert opinion

An expert in neurology criticised Mr L’s failure to operate at the correct level and advised that Mr G’s cauda equina syndrome was the result of a postoperative haematoma following the erroneous surgery.

The case was settled out of court for a substantial sum.

Learning points

  • Operating at one level above the intended site is the most common mistake in spinal surgery. This risk may be reduced by making an indelible mark on the skin above the bone or disc to be operated on and using an intra-operative x-ray to ensure the correct level (see guidelines by the Canadian Orthopaedic Association and the American Academy of Orthopaedic Surgeons).
  • If an error comes to light postoperatively, inform the patient and discuss the plans to rectify the mistake.
  • Document all events fully in the patient’s notes and complete the necessary clinical incident forms.
  • When obtaining the patient’s consent, as well as potential surgical complications, the patient should be advised of the potential of possible complications – ie, the risk factors when special circumstances exist.
  • Technology should always be used when it is available. If the usual technology is not available, then all options should be considered. This would include postponing the procedure or discussing the implications with the patient.

Further information

Goodkin R et al, Wrong Disc Space Level Surgery: Medicolegal Implications,Surgical Neurology, 61(4):323–41 (2004)

Ammerman et al, A Prospective Evaluation of the Role for Intraoperative X-ray in Lumbar Discectomy: Predictors of Incorrect Level ExposureSurgical Neurology, 66(5): 470–73 (2006)

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