Dear Panayot,

I have not experience in this type of surgery, but in Spain, any untoward outcome is potentially liable at court. A different thing is that judges find te surgeon guilty. A critical issue is  to have a signed comprehensive consent form. In case there is not consent form, you are not even covered by you private insurance.

Kind regards,

Juan

Thank you, Juan for your clear answer.

Dear Dr. Tanchev:

This is a very important question for every practicing surgeon. In US each state has slightly different laws. If it is proved to be negligence on the part of the Surgeon, then the surgeon is liable for judicial prosecution. It depends on so many things. The lawyer who takes up the case has to prove that it is negligence. If the surgeon can prove that it is not his negligence, there may not be any prosecution. It is a tricky question. Thanks for asking such important questions.

Thank you, Dr. Bollam for your interesting answer.

Panayot,

As you know my area of expertise is Total Joints but felt I could provide some insight to your question. I have provided expert testimony over the years in a variety of medical/legal cases from design, surgical technique and damages.

I for one have always stayed away from spinal cases and have been under the impression that even good outcomes often leave the patient dissatisfied. Knowing this the surgeon needs to have heighten skills in communication with his patient. You must prepare for the worst outcome and make sure the patient understands the risk of a poor outcome.

I would agree with both Juan and Papireddy on their comments. Patient consent form and disclosure forms are significantly important. Often these forms are not reviewed or updated and do not provide adequate risk information. In addition, the surgeon needs to review and be informed about the device patient "product" insert form  from the manufacturer. This can often be used against him if the case goes forward.

He also needs to know current statues of treatment in his area and must demonstrate expertise in this field. The most dangerous risks need to be highlighted  to the patient even if they do not occur often.

Mistakes happen every day in surgery and most cases are done by good surgeons with proper training. Preoperative planning which should include a significant amount of time in realistic discussion with the patient and family about risk factors with good documentation will reduce medical/legal entanglements.

Regards,

Tim

Dear prof Panayot,

Thank You for inviting me to discuss.

This is very important subject but I think not clear one answer. 

I am not a surgeron,

In Poland every patient  before operation get information about eventual complication and must signed (before 18 YO, must signed parents). 

If complication after surgical, consider the case a team of specialists.

 I do not know of such cases, and I wish you all surgeons and patients all successfull treatment. 

Thank you, Tim. Thank you, Dr.Korbel for your posts They provide important insights to

the problem.

Sub-optimal screw position is a reality in spine surgery, and fortunately rarely leads to catastrophic events but may cause subtle and difficult to recognise symptoms of aching, burning or unsatisfactory outcome due to root irritation. Furthermore, a sub-optimal screw position may lead to later migration due to less purchase and mechanical stability and thus cause serious sequellae. Any technical, tactile and imaging method must therefore be employed to avoid this, the only correct position of a pedicel screw is fully inside the bone. Navigation and 3-D intra-operative imaging may help, but no method is 100% fool proof, it all starts and ends with the surgeon being very aware and critical, but stll it may occur. Then, if things still go wrong and the surgeon can demonstrate that the patient was well informed, the procedure was carried out 'lege artis', anatomy was complicated and every precaution was taken, this should be considered a complication, not a legal offense. Complications should be cautiously registered and discussed in the team. If all that is in place, the surgeon in my opinion should not be liable, he or she will be devastated anyway.

Thank you, Dr.Castelein. My opinion is close to yours. Anyway, serious jatrogenic  injury to the spinal cord occurs. And this is s devastating situation for surgeons and patient. In my practice in cases with scoliosis where the anatomy is really very much changed, I prefer the hibrid instrumentation - hooks proximally and screws distally. It is much safer.

Dear Prof Tanchev, Very interesting and important topic. Because this is a large operative procedure performed on individuals who have altered spinal anatomy and often also have multisystem compromise. A high degree of correction carries a risk of neurological complications. Somatosensory evoked potential spinal cord monitoring reduces neurological deficits after scoliosis surgery. Each lawyer attemts to build a cogent argument to support his view of the case, based on factual data available from witness and documentation.

Dear  Prof. Tancher,

In Brazil, the understanding of judicial means, is that whenever there is damage to the patient, it is subject to financial repair. When the patient seeks legal redress he almost always wins. Even if the patient has undergone all care, even if the surgeon has clear informed consent prior to surgery, even if the risks and the need for intervention with the patient and his family have been widely discussed, and even if the surgeon has not Committed negligence, malpractice or recklessness. In the case of the last three, there may be a penalty in relation to the exercise of the profession and also penalty for repair of damages. Unfortunately this is the reality here.

Att,

Additional important facts that need to be taken into consideration before answering the question;

Was spinal chord monitoring being used?If so, were monitoring changes heeded and appropriate action taken

Was the offending screw removed as soon as the paraplegia was discovered..

Can it be proven that the paraplegia was solely caused by the screw, and not a result of correction in a difficult case?

andrew King

Dear Dr. King      My question is based on a hypothetical case. Unfortunately, it happens in reality although very rarely. Anyway, the answers to your questions 1 and 2 are "yes". Last question - "no".