Forty-three-year-old Ms M was referred for investigation of neck pain that radiated into her left hand. The surgeon, Dr H, diagnosed a C6/7 cervical disc problem, confirmed by a CT scan, myelogram and MRI. He recommended surgery, as he felt conservative treatment had failed.
Ms M was admitted ten days later. She signed a consent form, countersigned by Dr H. The operation was described as an anterior C6/7 cervical discectomy with extensive foraminotomy on the left side, resection of the posterior longitudinal ligament and anterior interbody fusion with plate and screw internal fixation. Surgery lasted 90 minutes.
In the recovery room, Ms M was noted to have normal neurological function and was moving all four limbs. One hour later, the anaesthetist was informed about a fall in the patient’s pulse and blood pressure and this was treated successfully with 500ml of Haemocel.
Five hours after the operation, Ms M complained that she could not move her legs or empty her bladder.
Dr H confirmed loss of motor and sensory spinal cord functions. An MRI demonstrated extensive bleeding into the spinal canal, lying anteriorly in the epidural space from C2 to C5.
Both the bone graft and the plate and screw were in good position. An hour later, Dr H found that Ms M was now paraplegic. He transferred her to the High Care Unit and treated her with steroids. He made a tentative diagnosis of a vascular problem, possibly ascending myelitis.
This conservative regime was maintained for a day or so, until her neurological status deteriorated further. Ms M was taken back to theatre some 44 hours after the original operation. Dr H, using a posterior approach this time, performed a laminectomy of C6/7 and T1. No specific abnormality was found and, on opening the dura, the spinal cord itself appeared normal. Dr H concluded that the patient’s quadriplegia was due to a vascular infarct, cause unknown.
The second operation did not relieve Ms M’s condition. She developed permanent quadriplegia at the level of C6/7,with total paralysis of her legs, distal paralysis of her arms and total loss of sphincter control
A case was brought against Dr H for not immediately proceeding to surgical drainage when faced with a combination of rapid onset paralysis and epidural haematoma.
Experts for the defence felt that Dr H’s initial conservative approach meant that he lost any opportunity of saving the spinal cord. The risk of causing permanent paralysis from attempting to drain the epidural haematoma was regarded as less than the risk of paralysis due to the haematoma being left undrained.
The case was considered indefensible and settled out of court in favour of the claimant for £286,000 plus costs.
- Surgeons should advise patients undergoing spinal operations of the possible risk of paralysis prior to signing a consent form. Discussions should be supplemented with explicit written information about the operation, its risks and the management of complications. Ideally, these risks should then put into context with information about the surgeon’s own experience and outcomes.
- When dealing with rare complications basic surgical principles should not be forgotten. Immediate surgical decompression is required to deal with an epidural haematoma; the earlier the diagnosis and intervention, the better the chance of neurological recovery.
- A combination of hypotension, bradycardia and urinary retention may be indicative of raised intraspinal pressure and should raise clinical suspicions prior to the onset of actual paralysis. Intraoperative monitoring of spinal cord function is now commonly used as an early warning system.
- Jankowski R at al, Acute Cervical Epidural Hematoma as a Complication of Anterior Cervical C5-C6 Diskectomy; Neurol Neurochir Pol, 37(4):955-62 (2003).
- Jones S J et al, Two Cases of Quadriparesis Following Anterior Cervical Discectomy; J Neurol Neurosurg Psychiatry, 74:273-276 (2003).
- Casebook 13:1 (February 2005) for advice on informed consent.