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Lumbar Spine Surgery / Spinal Surgery and Alleged Medical Negligence
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submitted by Dr. Gary Farr - Contact the author here.
Last Updated May, 20, 2002
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Spinal Surgery and Alleged Medical Negligence
R.W. Porter. Royal College of Surgeons Edinburgh, Nicolson Street, Edinburgh EH8 9DW
More than 2000 spinal operations are carried out in the UK each year. The decision when and whether to operate requires mature judgement. Spinal surgery is technically difficult, demanding a high level of surgical skill. It is learnt only by lengthy apprenticeship. The after-care is equally important. The personal supervision of the surgeon who leads a coordinated team of clinicians, nurses and physiotherapists will ensure the best results. It is inevitable and unfortunate that mistakes will occasionally be made and only careful attention to detail in the pre-operative assessment, meticulous surgical care and supervised post-operative management will ensure consistently good results. The spinal surgeon needs to remain up-to-date, be disciplined with a systematic and careful approach and lead a coordinated team to maintain the highest standards.
What is a patient entitled to expect at the present time and what are the standards that are recognized by the general body of spinal surgeons today?
Spinal surgery offers the patient a life-threatening procedure for a non-life threatening condition. There are always potential surgical complications, and although the benefits of surgery can be considerable, all reasonable conservative approaches should have been attempted first. When to operate is a difficult decision demanding fine judgement. There is a spectrum of opinion amongst surgeons for most spinal conditions. Some prefer a radical approach offering early surgery in order to hasten recovery of normal function. Others adopt a more conservative attitude. In the long term, most spinal conditions have a good natural history but disability can be protracted with conservative management. For example, there is no absolute indication for a surgical discectomy unless the patient has bladder symptoms. Even with severe sciatica and marked root tension signs, surgical treatment is not mandatory. With time symptoms will resolve, perhaps not completely, but at least to a manageable level. If symptoms have been present for only two weeks, it is not possible to predict the natural resolution. Without surgery, many of these patients will recover over a 3-month period with complete relief of symptoms and a return to work. If there has been no improvement over a 6-week period, however, the prognosis is less optimistic. Most spine surgeons would argue therefore that disc surgery for a patient who has had less than 6-weeks of symptoms is not good practice. They would say that unless there were bladder symptoms it was operating with unreasonable haste to offer surgery to a patient with less than 2-weeks of symptoms and this would not be a practice adopted by any reasonable spine surgeon.
Patients are sometimes distressed because they believe that there has been unnecessary delay in referral to a spinal unit. They may have suffered for many years with chronic back pain until finally they find an expert who is able to offer them successful spine surgery. They may remember years of pain and suffering, and at some time having been told the problem is psychological, and they might seek redress. Such a claim, however is unlikely to succeed because the surgery for chronic back pain is very unpredictable. There is always a body of reputable clinicians who would not recommend surgery for chronic low back pain. It is reasonable to operate but it is also reasonable to encourage patients to avoid surgery.
A more frequent claim for potential medical negligence is an unacceptable delay in a patient who has a bladder problem. Spinal pathology which compromises the sacral nerves supplying the bladder generally requires emergency treatment. Every surgeon knows that a patient who is unable to pass urine or alternatively is incontinent of urine has a potentially serious condition. Involvement of the L5 nerve may leave a patient with a foot drop and some numbness of the foot. It is a disability, but not serious even if it does not recover. However, involvement of the sacral nerves which supply the bladder is a major problem. When the symptoms have been there for more than a few hours the problem tends to be permanent, with loss of normal bladder function for a lifetime. The same nerves supply the bowel and sexual function, which are also permanently affected.
 Pathology which affects the conus can cause these problems. The conus is the lower end of the spinal cord at the level of the second lumbar vertebra and this can be compressed by fractures at this site. (See the diagram on the right). The conus may be compressed mechanically or its blood supply may be affected by the fracture. The sacral nerves can also be affected in the mid-or lower-lumbar spine. These nerves form the lower posterior part of the caudia equina. They lie fairly close to the lamina and they can be damaged by decompressive surgery at this level. A massive disc herniation can so compress the cauda equina that the sacral roots are pressed tightly against the lamina (cauda equina lesion).
It is therefore an emergency situation when a patient presents with back pain and bladder symptoms. These patients require rapid and comprehensive neurological assessment. The sacral nerves also supply the skin around the anus and perineal region. They are responsible for the tone of the anal sphincter muscles. Clinical assessment of this region confirms that there is significant problem with the sacral roots and early surgery is imperative.
The patient with the massive disc protrusion and bladder problems requires urgent imaging with MRI and rapid removal of the herniated disc, decompressing the cauda equina. The patient who has had spine surgery and in the post-operative period has evidence of sacral nerve dysfunction also requires urgent investigation and re-exploration for a treatable condition. The patient with an upper lumbar fracture and conus lesion similarly requires urgent decompression after appropriate imaging.
It is agreed that the longer the sacral nerve roots are compressed the less likely is their recovery and therefore, for the best result early surgery is required. It takes only a few minutes of complete loss of blood supply to the nerve roots for permanent damage to occur. Thus if compression is complete, in practice early surgery is generally too late. However the majority of patients have incomplete compression, when surgery within the first few hours can be fairly effective. The longer the delay, the less chance there is of recovery.
The diagnosis of back pain syndromes is made from the history and the examination. Investigations are supplementary, usually to identify the level at which surgery will be required. A plain radiograph is helpful in a negative sense. It can exclude advanced ankylosing spondylitis where the sacroiliac joints are sclerosed. It can demonstrate a spondylolisthesis which may be a hidden cause for back pain. It can also show up spinal metastasis from primary tumors elsewhere when these have progressed to an advanced stage. It will also show the presence of an osteoporotic fracture. However, for the majority of patients with low back pain syndromes the plain radiograph is negative. There is no good correlation between degenerative change in the lumbar spine and back pain.
The image of choice is the MRI scan. This will identify a disc protrusion, degenerative discs, spinal stenosis, infection and neurological tumors. It is so sensitive that pathology is often demonstrated which is asymptomatic. It is only of positive value when the images correlate with the clinical features in the history and examination.
When MRI is unavailable, a CT scan is the next best imaging modality, followed by myelography. It is unacceptable to operate on a patient without one of these supplementary investigations. Spinal surgery should be a once-in-a-lifetime experience. It is not an exploratory procedure in order to make a diagnosis; rather, there should be as much information available to the surgeon as possible prior to the operation.
There are no reliable procedures which tell us where the pain is coming from. Some clinicians will carry out facet joint injections or a provocative discography in the hope that this will identify the pain source by reproducing the pain. However none of these are totally reliable.
Depending on the patient's clinical problem, other investigations may be necessary. For example, a patient with osteoporosis requires blood investigations to exclude other sources of demineralization. They need blood tests for osteomalacia and {hyperparathyroidism} hyperparathyroidism, tests of the liver function and renal studies. However, for most of the patients having spine surgery, the history and examination often followed by MRI scan is the main pre-operative assessment. It may sometimes be supplemented by other studies.
It may seem obvious that surgery should be offered only when it is in the patient's best interest. However, it is unusual to have an absolute indication for surgery on the spine. The natural history of spinal disorders without surgery is generally good although disability can be protracted. It is necessary therefore for the surgeon to have a complete understanding of the patient's past history and social history to understand their lifestyle and occupational requirements before recommending surgery. It is important to understand the patient's expectations and whether these are realistic, and to ask whether surgery should be carried out at all. Simply because it is possible to change pathology by a surgical approach, does not mean that it is indicated. It is justified, however, in the patient who requires a rapid return to normal function because of the family or occupational situation.
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