Spinal surgery blamed for worsening symptoms

Miss L, a 39-year-old horse groom, had a long-standing history of low back pain, for which she had previously consulted a chiropractor. She attended her GP after experiencing a sudden worsening of pain along with saddle paraesthesia, bilateral leg numbness and urinary incontinence. Her GP was concerned about a possible diagnosis of cauda equina syndrome and referred Miss L to the emergency department.

A magnetic resonance imaging scan performed the same day showed a bulging intervertebral disc at L5/S1 and she was referred to the neurosurgical team who, following review of the images, recommended Miss L was discharged home with analgesia.

However, Miss L continued to experience significant back pain, now radiating down her left leg with ongoing paraesthesia to both buttocks and requested to be seen by a spinal surgeon on a private basis. She was therefore referred to Mr W, consultant spinal surgeon, and was reviewed several weeks following her discharge from hospital.

On examination, Mr W identified a reduction in lumbar flexion and a severely limited straight leg raise on the left side, with the right side being normal. Sensation was reduced to her left calf and foot, her right foot and both buttocks. Power to the left ankle was reduced but otherwise normal to the lower limbs. Miss L also complained of ongoing episodes of urinary incontinence.

Mr W reviewed the MRI scan from the hospital and considered this demonstrated disc degeneration at L4/5 and L5/S1, with a left sided disc protrusion at L5/S1 that was migrating centrally.

Mr W recommended surgery in the form of a posterior lumbar interbody fusion, cautioning Miss L that this may not relieve all of her pain and other symptoms, and was primarily intended to prevent further deterioration. She was informed that there was a small risk surgery would make matters worse, and that an alternative option was to continue conservative management.

Miss L consented to surgery after considering her options, and this proceeded uneventfully.

A month following the surgery Mr W reviewed Miss L. Miss L reported that the back pain had resolved, her leg pain had lessened and, while her incontinence and numbness had not completely resolved, both were improved from the situation prior to surgery.

However, around a year later, Miss L once again developed back pain with worsening bladder dysfunction and numbness to her feet and buttocks, along with disturbance of bowel function, stating these symptoms to be worse than those she had experienced prior to her surgery. A further MRI scan was arranged, which did not demonstrate a cause for the symptoms. 

Miss L brought a claim against both the hospital and Mr W, alleging the hospital failed to diagnose acute lumbosacral radiculopathy by means of a lumbar puncture and neurophysiological studies; that Mr W advised and performed unnecessary spinal surgery; and that both the hospital and Mr W should have prescribed a course of high dose oral steroids, which would have relieved her symptoms and prevented their recurrence. It was further alleged that the surgery was the cause of her worsened symptoms.

Outcome

The case was considered by Medical Protection to be complex, with a number of allegations against both the hospital and Mr W, and with Miss L’s solicitors suggesting that the investigations and treatment that were performed would not normally be routinely carried out for such symptoms.

Opinion on Mr W’s actions was sought from an expert spinal surgeon, who concluded that surgery was an appropriate course of action to offer under the circumstances; and that although Miss L continued to experience symptoms, her medical records indicated that she did experience improvement following the surgery, and there was no indication it caused harm.

On receipt of the expert report, the case was again fully reviewed by Medical Protection’s medical and legal team, and it was considered that the case should be robustly defended. A barrister was therefore instructed to draft a formal defence on Mr W’s behalf and, following receipt of this, Miss L’s solicitors discontinued the claim.

Learning points

• Comprehensive and clear documentation of any history and examination performed is vital should there be a later challenge to the diagnosis made at the time of the consultation.
• Risks and benefits of any surgical procedure offered, and the alternative options available (including the option of doing nothing), should be fully explained to ensure that decision-making and consent are informed.
• In an elective situation, time should be provided after the consultation and prior to scheduling surgery to allow the patient to weigh up the options and form a considered view as to whether or not they wish to proceed.