Mr A, a 50-year-old engineer, was referred to Mr Z, consultant neurosurgeon, with increasingly severe back pain and additionally pain and weakness in his right thigh. Mr A had required high doses of opiate analgesia for pain relief and had been unable to work for several months prior to the consultation.
An MRI scan was organised, which demonstrated severe spinal stenosis at the level of T11/T12. Mr Z advised the patient that the spinal stenosis should be decompressed and that the symptoms in his right leg were related to meralgia paraesthetica, which could be dealt with at the same operation. Mr A underwent posterior discectomy of T11/T12 and decompression of the right lateral cutaneous nerve of the thigh.
Postoperatively Mr A complained of pain and weakness in the left leg and thigh and loss of movement in the right leg. A further MRI scan demonstrated a haematoma at the level of T12. Despite further emergency surgery by Mr Z, there was no improvement in Mr A’s lower limbs and three weeks later he was transferred to a long-term rehabilitation unit. After a further three months Mr A was eventually able to return home. He had control of his bladder and bowel, could stand with help but was unable to walk and was no longer able to work.
Mr A commenced legal proceedings against Mr Z, citing inadequacies in informed consent: specifically that Mr Z failed to warn him that the procedure carried the potential risks of severe neurological complications. It was also alleged that Mr Z was negligent in carrying out the thoracic spinal decompression, with particular regard to the posterior transdural approach that he used.
It was evident from the notes and consent form that there was no documented discussion regarding any risk of neurological deficit relating to the operation and Mr Z acknowledged that he had not discussed such potential complications with the patient. A series of up-to-date independent neurological examinations and tests on Mr A demonstrated features entirely consistent with a spinal cord injury at the level of T12, in keeping with surgical trauma from the operation carried out by Mr Z.
Several expert neurosurgeons, commenting on the case, agreed that the posterior transdural approach employed by Mr Z for removal of a central thoracic disc protrusion had a much higher risk of spinal cord injury compared to the preferred anterior approach, as this would have posed less risk of serious neurological injury. They concluded that Mr Z’s procedure was not supported by the modern neurosurgical literature, was not the standard surgical approach and fell short of what would be considered reasonable spinal surgical practice. The case was not defensible and settled for a substantial sum.
- With any operation it is important to have a detailed discussion with patients regarding the potential for complications, so that they can make a balanced decision as to whether they wish to go ahead with the procedure. The discussion should include common/minor side effects as well as rarer, serious adverse outcomes that can produce permanent disability or death.
- Discussions with patients should always be thoroughly documented. Statistically, decompressive surgery of the thoracic spine has the highest risk of neurological complications, compared to decompressive surgery of the cervical and lumbar spine, given the size of the spinal canal relative to the spinal cord and the spinal cord’s relatively poor blood supply in the thoracic spinal canal. It would be expected from the reasonable spinal surgeon to mention the risk of a significant neurological deficit from surgery in this region.
- Clinicians are obliged to keep up-to-date in their field and undertake procedures that are recognised as standard by their peers with acceptable outcomes. Clinicians additionally need to demonstrate evidence of continuing professional education as part of their appraisal and revalidation processes.