Neurosurgery expert witness discusses an inadvertent durotomy when a drill slipped during lumbar fusion surgery

A neurosurgery expert witness opines on a case that involves an eighty-two year-old male patient with an extensive past medical history which included stage three chronic kidney disease, type II diabetes, hypertension and degenerative disk disease. The patient was under the care of an orthopedic surgeon for back pain caused by the degenerative disk disease. The surgeon recommended that the patient undergo an L4-5 lumbar fusion surgery. The patient agreed to the procedure and was cleared for surgery after pre-operative evaluation. During the procedure, the surgeon informed the patient’s family that while he was “drilling arthritis off, the drill slipped and hit the patient’s spinal fluid and may have severed a few nerves.” As a result of the error the patient required a lengthy hospital stay. He had urinary catheter in place for an extended period of time and developed a bladder infection during his post-operative recovery. The patient developed decubitus bed sores that required multiple irrigation and debridement. The patient also developed cauda equina syndrome which remained symptomatic following discharge and never resolved. The patient is left with permanent incontinence.

Question(s) For Expert Witness

1. How often do you perform these procedures?

2. Have you ever had a patient experience severe incontinence post-op?

Expert Witness Response E-001529

I assume that this surgery was performed from the posterior approach and that the intraoperative neurological disaster was related to a lumbar decompression either prior to or following the lumbar fusion. The history of the presenting complaint would suggest that there was an inadvertent durotomy with severe neurological compromise in an already frail and immune compromised individual. During my years in clinical practice I performed literally hundreds if not greater than a thousand such procedures. I have fortunately never rendered a patient permanently incontinent post-surgical decompression but as director of a level one spinal cord injury unit I did treat multiple such injured patients, some of whom had suffered iatrogenic injuries like the patient in this case. Although this is a known complication of the procedure, it is very rare and could be a breach if the patient was not informed of this prior to the procedure or if there was physician error during the procedure. It is vital that great care is exercised when using potentially dangerous tools around delicate structures such as nerves and vasculature. It is an occupational hazard that neurosurgeons face on a daily basis and the surgeon in this case should have been more careful.