Physician’s Failure to Inform Leaves Patient Disabled

Case Summary

In this case, the patient underwent elective Direct Lateral Interbody Fusion (DLIF) to alleviate chronic back pain. The L4-L5 level procedure resulted in the loss of nerve conduction in the lumbosacral plexus. The patient developed post-surgical left lower extremity weakness and complications including the inability to walk without an assistive device. As she did not receive a full disclosure regarding the possible surgical complications of the procedure, this patient was not provided with information sufficient to be considered informed consent.

Case Theory

A DLIF surgical candidate may have damaged or degenerated spinal disks or a spinal condition like spondylolisthesis. In DLIF surgery, the surgeon removes the damaged disc and any bone spurs. The surgeon then fuses the two affected vertebrae together with a bone graft or prosthetic device. A metal plate and screws stabilize the bones. DLIF surgical complications include anterior thigh pain, numbness, dysesthesia, and hip flexor weakness. In DLIF, it is known that the lumbosacral plexus is at risk of damage. Most DLIF injuries affect the L4-L5 portions of the plexus.

The lumbosacral plexus is a network of nerves that arise from the lumbar and sacral roots and divide into anterior and posterior branches. They communicate through the lumbar plexus. The anterior branches supply flexor muscles of the thigh and leg. The posterior branches supply the extensor and abductor muscles. Lumbosacral plexus injuries are uncommon. There are several causes of problems with the lumbosacral plexus. These include pelvic trauma that damages the roots or nerves and cancers of the intestines, bladder, or prostate that invade the plexus. It is also possible for plexus disorders to occur because of direct pressure on nerve roots and surgical errors.

Informed Consent

Spinal fusions, like all surgeries, pose risks to the patient. With fusion surgery, there is a risk of nerve pain and muscle weakness. A valid surgical consent requires the patient (1) to be competent to make the decision; (2) to have received sufficient information; and (3) to not be acting under duress. As well as addressing all risks and complications, the surgeon should also be aware of factors contributing to an increased risk of transient or permanent nerve injuries. In this case, there was a violation of the standard of care as the surgeon failed to inform the patient of the potential for a poor surgical outcome. This failure is particularly egregious since the patient would have refused surgery if she had known about this possible outcome.

Expert Witness Specialities

Orthopedic Surgery

An orthopedic surgery expert with experience in DLIF procedures can opine and speak to informed consent and the DLIF surgical procedure injury.

Questions for Expert Witnesses

• For DLIF procedures, what is the standard of care for informed surgical consent?
• Was it the surgeon’s duty to inform the patient of the risk of nerve damage and loss of function?
• Was the L4-L5 injury preventable?
• How common are DLIF procedure complications?
• What is the patient prognosis in this case?

Expert Witness Involvement

Here is what the orthopedic surgeon in this case had to say:

Expert Witness Response E-007022

I am a board-certified orthopedic surgeon who is fellowship trained in spinal surgery. I am on faculty at a major medical school and practice at a large academic medical center. I routinely perform lateral interbody fusion surgeries in my practice. Nerve injury is a complication of virtually every single spinal procedure, and it should be clearly communicated to the patient prior to surgery. I have reviewed at least one case involving an injury to the lumbar plexus occurring during a lateral interbody fusion procedure.