A 38-year-old female with a long history of episodic low back pain presented to her primary care physician with a recent history of severe right lower back pain, with some radiation into the right leg and numbness along the lateral aspect of her right thigh and calf. An MRI showed degenerative disk disease, a mild concentric disk bulge at L4-5, and a moderate size right paracentral disk herniation. The PCP referred her to a neurosurgeon who recommended a right L5-S1 microdiskectomy. In his preoperative note, the neurosurgeon noted that the patient had a long history of right lower extremity radiculopathy refractory to conservative measures.
On the day of surgery, the patient was placed under general anesthesia in the operating room before a needle marker was inserted into her vertebrae. The attending was present with his junior and senior resident, and explained to them how the procedure should evolve. Unbeknownst to the team, the X-rays had been put up backwards. The junior resident made a left midline incision over the spine. Perceiving that it would take 20 minutes before they would expose the vertebral body, the attending surgeon left the operating room and went back to his office. Soon after he left, the senior resident was called away for an emergency.
The junior resident proceeded without the attending surgeon and carried down the incision to the interspace of L5-S1 where a left hemilaminotomy was done. When the attending neurosurgeon returned to the operating room, he immediately discovered 1) his senior resident had been called away, 2) his junior resident was involved in separating and clearing the muscle and tissue from the spinal column, and 3) the resident was operating on the wrong side. The attending and junior resident closed the area on the left that had been incised, and the resident proceeded to do a similar pass down the right side of the interspace. The neurosurgeon removed the ruptured disk without any difficulty.
Immediately following surgery, the patient began to complain of new symptoms involving her left side. In the recovery room the surgeon informed the patient that they had separated tissue and muscle from the left side as well as the right. She asked if her new left-side symptoms were related to the operation, and the surgeon downplayed the possibility, saying the incision was minimal. After discharge, the patient called her surgeon’s office twice because of pain. Without speaking with her directly, he recommended she restrict her activities, and he prescribed anti-inflammatories. The patient did not return for her follow-up appointment. Her subsequent course involved multiple hospital visits for severe left leg pain that was new since the surgery.
