A 20-year-old diabetic suffered from ocular nerve damage following prolonged back surgery.
- Patients should be confident that treatment decisions are not unduly influenced by staffing, financial, or scheduling factors.
- Advice about the risks of treatment should weigh those risks against what’s important to the patient.
- Clear plan, with checkpoints that provide an opportunity for adjustments, can reduce the risks of long and complex procedures.
A 20-year-old male with insulin dependent diabetes, injured his back on a submerged rock while jumping off a boat dock at a friend’s home. He was taken by ambulance to a local hospital, then transported to a Boston Emergency Department. He arrived at 8:30 p.m., Saturday, June 28th.
In the ED, The patient was seen by a neurosurgeon and an orthopedic resident. A neurological exam performed shortly after admission showed upper leg weakness and no reflexes in his lower extremities; X-rays revealed a burst fracture of his lumbar spine at L-4. The resident placed the patient on steroids and had him admitted. Over the next 40 hours, the patient’s neurological condition improved, although he had decreased sensation below both knees, and no reflexes in either leg.
Monday afternoon, a staff orthopedic surgeon reviewed the patient’s X-rays and advised the orthopedic resident that surgery was necessary. Tuesday morning, the staff surgeon discussed with the patient (and his mother) the risks of the surgery, including nerve and vessel damage, bleeding, infection, and non-union. Neither the surgeon, the patient, nor the record recall a discussion regarding the risk of vision loss.
The surgery started at 1:30 p.m. Wednesday with the patient on his back. The attending orthopedic surgeon (assisted by a general surgery resident) removed part of the vertebra and bone fragments at L-4. He then placed a cage in the area of the partially removed vertebra. Six hours after the procedure began, after verification from the anesthesia resident that the patient was stable enough for the second stage of the procedure, the patient was turned face down. The surgeon then mechanically secured the spine. He elected not to extend the surgery further to remove one bone fragment in the spinal cord that he determined was not pressing on any nerve roots. The posterior surgery ended at 1:45 a.m., Thursday, July 3rd. During the 12 hours of surgery, the patient lost nine liters of blood, which required administration of 23,000cc of fluid.
Post-op, the attending surgeon left for a camping trip in Maine. The patient was taken to the ICU and remained intubated. His face was swollen from the fluid replacement and he did not open his eyes for most of the day, Thursday. Around 7:00 p.m., the patient complained he couldn’t see. When the ICU staff was unable to reach the attending surgeon, they consulted with Ophthalmology and Neurology. Hyperbaric oxygen treatments were discussed. At midnight, another surgeon examined the patient, who was now blind. Testing revealed that damage to the posterior optic nerve—likely caused by the heavy blood loss during the spine surgery—had caused the vision loss.
In addition to the permanent vision loss, the patient also suffered permanent paralysis of the front muscles of his right lower leg, causing foot drop.
The patient sued the attending and resident surgeons, alleging that their decision to complete both stages of the procedure during one operating session was directly responsible for his blindness.
All parties agreed to take this case to mediation, which led to a payment in excess of $1 million.
- The patient contends the surgeon was negligent in recommending surgery for the repair of the burst fracture at L4, rather than a trial of nonoperative treatment. The surgeon’s recommendation was based on the patient’s neurological status and the angle of his spine resulting from his diving accident.
Treatment decisions for trauma patients are particularly susceptible to hindsight when the outcome is less than what the patient expected. Patients and/or their families should be confident that the decision is based on what’s best for the patient’s long-term quality of life, and is not influenced by staffing, financial, or scheduling factors.
- The patient argued that he could not fully exercise his informed consent to the surgery because he was not advised of the risk of vision loss. The surgeon countered that, even if the patient had been advised of the risk, he (and any reasonable person) still would have proceeded with the surgery.
Advising a patient about the risks of treatment is a balancing act in which the likelihood of any risk is weighed against what’s important to the patient. A slight risk of hearing loss may impact the decision of a musician, but not a lawyer. In this case, the patient’s diabetes might have justified a discussion of the risk of vision impairment.
- The surgeon and anesthesiologist felt that one long operation was preferable to two shorter ones. The patient alleged that, in light of the extensive blood loss, the surgeon was negligent in choosing to go forward with the second stage of the surgery rather than waiting several days before proceeding with the second stage.
A team preparing for a long and complex procedure can reduce the risk of compromising the patient’s health by having a clear plan with checkpoints that provide an opportunity for adjustments. If possible, having a disinterested third party facilitating those discussions helps keep them focused on the patient’s best interest.
- The patient claimed that the surgeon’s technique for this procedure caused both his blindness and the trauma to the nerve roots affecting his right leg.
Spinal surgery, with its inherent risk of nerve damage and paralysis, requires special attention to the patient’s expectations and fears, and clear documentation. It may be prudent to include the possibility of post-operative vision loss in the operative consent, since the damages can be severe.