Problems arise from spinal anaesthesia

This case is based on a real scenario, with some facts altered to preserve confidentiality.

A 48-year-old man underwent abdominoplasty and liposuction. At the pre-operative visit, the consultant anaesthetist proposed general anaesthesia along with a spinal anaesthetic for the purpose of post-operative pain relief. Both the patient and his partner, who was present at the discussion, were clear that the patient’s tolerance for pain was poor, and accepted the anaesthetist’s view that this would provide superior pain relief compared to other options.

However, no risks of spinal anaesthesia were documented or discussed, and no alternative forms of analgesia, such as a PCA, were offered. 

After induction of general anaesthesia, spinal anaesthesia was performed with the patient in the left lateral position. On a third attempt, 3.5mls of a mixture of bupivacaine and diamorphine was injected at the L4/5 interspace with a 25G pencil point spinal needle.

The operation was three hours in length and the anaesthesia during this time was uneventful. Following transfer to the ward post-operatively, the patient complained of severe burning and tingling pain to his left calf. Analgesia, including morphine, was administered. An ultrasound did not show evidence of a DVT. 

The pain continued, and over the next 24 hours the patient also complained of weakness to his left leg and an episode of urinary incontinence, along with reduced perineal sensation. 

An MRI scan with contrast was performed of the patient’s spine, and this demonstrated a hyper-intense lesion extending from the conus medullaris to the level of T12, considered by the reporting neuroradiologist as being suggestive of a contusional injury. 

Six months later, the patient brought a claim against the consultant anaesthetist, alleging the spinal anaesthesia was responsible for ongoing symptoms of severe left leg pain and leg weakness, such that a wheelchair was necessary for mobility, as well as loss of bladder control. 

The expert witness acting for the claimant considered that spinal anaesthesia was not clinically indicated for the operation performed and that informed consent had not been obtained. The expert was critical of the decision to perform the spinal anaesthetic with the patient asleep and considered it was likely the block was performed higher than the stated L4/5 interspace, causing direct damage to the cord.

An expert providing a report on behalf of the consultant anaesthetist gave a very similar opinion. It was considered by both experts that the symptoms experienced by the patient would be consistent with injury to the spinal cord and that on balance of probabilities the cord had been injured by the insertion of the spinal needle. 

Further reports were obtained by both the claimant and Medical Protection on the matter of condition and prognosis, and in a joint report the experts agreed that the patient’s neurological deficits were permanent and unlikely to change. 

Following the receipt of expert reports, the claim was settled for a sum totaling over £3m.