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SNI Digital, Innovations and Learning, a 3D Live video journal, which is interactive with discussion. In association with SNI, Surgical Neurology International, a 2D Internet Journal, is
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pleased to present another in the SNI Digital series on controversies and spine surgery This program was presented on December 27, 2024.
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Nancy Epstein is the person presenting this lecture. She's the professor of clinical neurosurgery at the School of Medicine at the State University of New York in Stony Brook.
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And she's the editor-in-chief of Surgical Neurology International The second talk in this two-part series.
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is entitled Lessons from Malpractice Cases in Lumbar Spine Surgery. So here, negligent lumbar surgery, I'm going to tell you about a failure of an acute care facility to diagnose an acute
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corticoyne syndrome. I'm going to tell you how with minimally invasive operation, it may be the wrong operation for that specific patient. Doing the wrong operation should be reversed by then doing
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the right thing afterwards, recognizing in this case a CSF leak and treating it that didn't happen, leading to arachnoditis. I'm going to give you
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a few cases where they fail to diagnose and treat corticoyne syndromes and a failure to emergency remove an epidural abscess in a patient who has already paralyzed leading to permanent paralysis and
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how doing an unnecessary minimally invasive tea lift and a patient who just needed a decompressive laminectomy caused a permanent foot drop and partial cotocornic syndrome that could have been avoided.
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by again, just doing a straightforward operation. So we're going to take one by one, and we're going to dissect the different elements. Just as a reminder, here is your quarter-quiner, T12L1
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down to L5S1, and here are your sacral nerve roots. Bemoral nerve is going to give you those proximal deficits, you leave psoas and quadriceps,
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sciatic L5 and S1, extensor houses, drosine, plantar flexor, weakness, sensory changes, et cetera, and the sacral roots with the sphincter dysfunction
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Just to remind everybody, you've got central, you've got lateral, you've got foraminal, and you've got forlateral dyscrenaations.
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And in addition to the dyscrenaations, you can have unilateral or bilateral recessinosis. My father was a neurosurgeon and also a medical illustrator. And this is an example of bilateral lateral
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recessinosis. You can see the hypertrophy deoligament, massively hypertrophyte piscet joints And basically what I often tell. physicians at this point is, you know, have your patients put their
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arms in front of them and pretend that their head, that they are the vertebral body, the space in front of the spinal canal, put their arms out and then put their elbows together and look at how
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much space is left over and that's really a stenotic spinal canal. So here, this is what you see and this is what you get. You may have on the other hand multi-level laminotomies that may be done
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on either side to deal with this. Lots of times though, that's not sufficient if you have tremendous stenosis because you just don't have really much of a laminar here at all and then coronal
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hemilaminectomies. We went for years trying to preserve some of these spinnest processes and interest by this ligament. It's just a waste of time and with your microscope you want to be able to
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angle and really work in that lateral recess on either side trying to preserve your facet joints to preserve stability to avoid choosing these patients, but
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Viral tummy laminectomies are extremely useful operations if you have one level pathology. On the other hand, if you have multi-level stenosis,
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with central stenosis, you wanna do that multi-level laminectomy and decompress the patient completely. So this is an example of what an acute synovial cyst may look like here. I have a
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kerosene underneath here. Look, you've got the cotenoid nicely.
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This has already been dissected nicely, completely away from the dura. So you're not going to get a CSF leak in this case. If you cannot do that, then you have to sort of marsupialize and take a
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portion of that synovial cyst and leave the portion that's densely adhered to the dura so you don't get a leak, but you have an adequate decompression. This is pathologically what that cyst may look
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like. And then here is a classic MR scan, an axial view,
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L5S1, L45034, L23. That's your synovial cyst that's being shown here. And here on an axial view is your synovial cyst being seen clearly. So this was a case
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where patient woke up one morning and suddenly developed pain, non-distantly weakness and a leg just really literally could not get out of bed. Went to an acute care facility. The acute care
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physicians did not do much of a neurological exam because nobody there was a neurologist. They didn't call in any consultants. This was not a hospital They did not refer her to a hospital. They
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ordered a non-contrast CAT scan. And the CAT scan was read as normal. Well, actually, this person was then discharged home in a wheelchair. Actually, she happened to not even live on land, so
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to speak. She lived on a boat. She happened to be a friend or compatriot. And she called me. And I said, this doesn't sound right. Show up at X Center We examined her, she had a pliegic leg.
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by questioning her, which is, you know, 910 of this is doing a history. And she had not urinated since the morning. She said, Oh, but I didn't have anything to drink. I said, That doesn't
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matter. I said, On the CAT scan, it certainly looks like she was in retention. And on the CAT scan, I also saw an acute synovial cyst. Oftentimes you're not gonna see that on a CAT scan at all.
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That means that there was some calcification of the lining of this joint, of this cyst We got a stat MRI scan performed. It confirmed the acute cyst and her quarter-coiner compression. And
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literally, yes, she had an MRI scan on a T2-weighted image showing that the cyst filled this spinal canal. And on the T1 enhanced study, again, huge synovial cyst filling the canal. So what did
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we do? Well, this again was the axial image of the same thing. You can see the synovial cyst I purchased your ligament as seen here. partial extrusion of a synovial cyst coming right out of the
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piscet joint. I perturphied a thorotic piscets on both sides.
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Patient was immediately referred to a hospital. She had a stat laminectomy performed within hours and she regained full function. Despite the fact that she went in with a bladder that was out for
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numbers of hours, she got full function back. It was not 24 hours. This really comes under the guise of, if a patient has any degree of paralysis and photo-coina syndrome and loss of sphincter
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function, you know, they say for restrokes, you know, time is brain here, time is spine. She regained full function and actually she did not sue. But the lessons learned here is start with
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doing a good neurological exam and actually, I mean, more importantly, do a decent history. Get an MR scan. CT scans are not going to show you acute deficits, acute pathology in the spinal canal.
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They're just gonna show you bone. And especially if you're looking for infection, you're not gonna see anything like an abscess for like six weeks. And don't discharge paralyzed patients. There's
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gotta be something going on there. If you think it's psychological, call psychiatry. If you think they're really paralyzed, then guess what? Get call a console, get the neurologist, get the
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spine surgeons involved, get somebody else who can take a better look at what you're seeing, because lots of times you don't have the expertise as an internist or a pediatric specialist or a PCP in
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that acute care facility. And even in the emergency rooms, your emergency room physicians, oftentimes you're going to miss this too. So get those consults involved. You're going to do something
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right for that patient.
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And here's another case where - The patient was advised to have a minimally invasive operation. It always sounds good to the patient. Oh, the incision is going to be very small. Of course, the
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most important thing is what is done underneath the skin to do that decompression to take care of the neurological problem. And here, the fact that it was a minimally invasive procedure, they did
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it with a metrics discectomy. They had no room to adequately decompress and take out this disc. And then the next thing they know, they have a CSF leak And I've seen other cases where I was asked
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to operate on a
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patient's secondarily. And they said, oh, I still have my pain. I had a minimally invasive procedure. I went in on one of those. And what did I find? Immediately, a huge amount of scarring
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right dorsal to the fecal sac, because obviously, with the metrics discectomy, they got right into the dura. And they never got anywhere near the disc that was laterally In another case,
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the patient actually had an incision that was just skin deep. there was nothing done in the canal at all. So, and oh boy, by the way, the operative notes, very extensive voluminous, but that
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nothing to do with what was actually done. But in this case, a minimally invasive discectomy was done. They encountered a CSF leak, and likely the fact that it was an inadequate exposure
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contributed or caused the leak, it had been the correct operation. You can always say, well, a leak can occur. But if you do the wrong operation, is that really just, you know, a standard of
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care, that's just because that's one of the risks of these procedures, and in any case, this led to intraoperatively, you should then increase your exposure so that you can repair the leak. That
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was not done. The leak was poorly repaired and obviously, recurred postoperatively. Eventually, as patients developed the rachnoiditis, but that was because postoperatively, the leak was never
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dealt with. So here, you just have an intraoperatively This is just an example, not this patient's films. Obviously, that's where the leak occurred, and then it can result in massive extension
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into the subcutaneous soft tissues.
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But here, a minimally evasive matrix discectomy was formed, was done, there was poor exposure. Likely it contributed to the CSF leak. The poor exposure likely led to a poor repair. Okay, it led
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to a post-op recurrent leak, but the symptoms were ignored The wound was full and patchalous, okay, and every time the patient stood up, they had severe postural headaches. They started
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developing some sexual dysfunction, some cranial nerve dysfunction because of, you know, you can get with postural hypotension, you can get, you know, durable enhancement and all kinds of other
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cranial findings on MRI scans. But in this case, there was no post-op MR done for months, months of complaints. The patient was also seen by, you know, you can say, well, it was just seen by
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the PA or the nurse practitioner and didn't see the doctor, but the doctor was in there on several of those occasions and was still responsible for co-signing these charts, but just basically the
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patient was ignored. And the patient had no re-operation, and by that time had developed adhesive arachnoiditis that again results in a perpetual and often progressive neurological deterioration
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syndrome. And this actually went to trial, it was a hung jury, but the lessons learned from this case is avoid misusing minimally invasive procedures. If you need an open operation, do it. For
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leaks enlarge the wound, enlarge the exposure, do a decent repair to avoid the recurrent leak, and do a timely post-operative MR. You know you had a leak. Why not repeat the MRI scan to document
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what the problem is to see if you could fix it, to make sure your patient's not gonna end up with a permanent andor a revocable and miserable neurological deficit.
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Okay. The background for this case, by the way, is just, you know, as a reminder. If you have a patient, you have a CSF leak, you know, use a microscope. You know, loops are really not good
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enough because when you repair these, you really want your assistant to be able to help you. So the microscope that's sitting in the corner draped with, you know, everybody's laundry on it, you
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know, take it out of the corner, bring it to the operative field, and use it. And then under the scope, use seven or gortech sutures. Why these are gortech sutures? Why use a gortech suture?
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The suture itself is smaller than the need. I mean, the suture itself is bigger than the needle. So wherever you have a puncture hole, you pull the suture through, it's going to occlude that hole.
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Okay, they're also non-resorbable sutures. And once you've done that, you have then between the sutures you can put in little microdural staples, grafts, muscle grafts do not ever use a fat graft.
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They just shrink and disappear and go away. don't use a running suture, by the way, because if it loosens, the whole thing falls apart. Duragen is microfibular collagen, and then you can use
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some of the various fibrin sealants as well. And that just happens to be one of them. Okay. And here is just, I threw this as an example of, there's so many cases that I've seen over the years
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where patients went to emergency rooms and the emergency rooms just failed to diagnose and then treat a water-quinas syndrome And here's just an example of a hypothetical patient, not this specific
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patient's image, big disc herniation on an MRI scan seen in both of these cases. And here's your figurative diagram. By the way, if the disc fills the spinal canal, maybe a full blown
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quarter-quinas syndrome, partial quarter-quinas syndrome, maybe a lateral disc herniation. And again, a partial quarter-quinas syndrome, maybe there's weakness of one leg, not both. There's a
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partial loss of bladder function and partial loss of saddle sensation loss, et cetera. patients, by the way, and physicians and multiple depositions that I've seen have no idea what a partial
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court of coin syndrome is. And if you don't know what a partial court of coin syndrome is, you're not going to understand a complete court of coin syndrome.
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These patients present to the emergency rooms on several occasions, oftentimes no labs, especially if they're women. They said, oh, well, you're just hysterical. No studies are often done. And
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if a study is done, it's often a CAT scan that's not going to show you the pathology Furthermore, they're often very poor neurological exams or no exams done whatsoever. Sometimes you'll have an
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exam. Well, the patient, they could push my hand up or down with their toes because they lift their legs off the bed, oftentimes that's not tested. Almost never do they do a rectal exam to see if
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there's any sphincter function loss. And by the way, they almost completely forget to say, hey, when was the last time you urinated? Do you have a full bladder? Are you having abdominal pain?
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And is your abdominal mass actually your full bladder? but oftentimes no neurology consults, no spine surgery consults, despite the fact that your emergency room physicians or hospitalists or
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general internists do not know how to do these neurological exams adequately. They're not aware of the partial, much less complete coder-coina syndromes. And ultimately these patients are sent home,
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they come back with a full-blown paralysis, loss of bowel and bladder function, loss of sphincter function. And these cases typically settle, but the lessons learned here is, you know, in the
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emergency room or, you know, even primary care locations, you need to order labs, you need to order MRI scans early, not just CT scans, get your consults, and don't discharge paralyzed patients.
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You know, if you think that it's psychological, get a psych consult, otherwise get a neurology or a spinal consult
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And here's another case, case four, where the patient presented. almost fully paraplegic with loss of bladder function, and this was due to an acute abscess.
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This is like the patient's images, but not the patient themselves. This patient had multiple previous ER visits, no labs, no studies, no diagnosis. By the way, you know, ESR and CRP are gonna
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be, your study's gonna show you if the patient really is septic. Patient ultimately returned to the hospital, nearly paraplegic with loss of bladder function The STAT labs and MR diagnosed the
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epidural lumbar abscess very nicely. They did call a spinal surgeon. The spinal surgeon said, okay, call me after you have that MR, both with
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and without gadolinium. Spinal surgeon was cold. Spinal surgeon didn't show up for consultation for hours, despite doing
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ultimately they did a consultation that night and then didn't operate that night. didn't plan to operate that night. Patient therefore remained collegiate, and this case was settled. And again,
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the lessons learned, recognize quarter coin syndrome, show up and operate in a timely fashion.
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And operate, quote, the sooner, the better, because this is what you would want done, this is what your relatives would want done, this is what your patients need, okay? So one of the last
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groups is to look at just, you know, grade one spondylilisis, here you have an image of the vertebral body, there's some forward slippage, and you have a, this happens to be a lysis defect, but
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other MR and CT scans, here's an MR of a typical grade one L45 spondylolisisis.
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Okay, there's no lysis defect here, and here happens to be, you know, L5S1, grade one to two spondylolisisis with lysis, okay So one of the last cases is unnecessary. minimally invasive,
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transfer aminolumbar antibody fusion, done in a patient, in their 60s, the MRI scan showed L45 stenosis and the dynamic x-rays showed a static mild grade one's slip, spondylisis at that four or
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five level. The geriatric patient with all these findings, x-rays showed no active motion
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MRI scan again showed mild stenosis at that level.
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And what happened here? Well, the patient had been seeing one physician for a long period of time, several months, and the surgeon had planned a laminectomy. The patient had also gone into a city
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to get an official additional opinion from an academic medical center and they also recommended a laminectomy She went back to this other surgeon for various reasons. And the week before surgery, he
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said, I'm going to have my partner do a minimally invasive transformal lumbar antibody fusion. There was no effort made to have the patient seen or examined by this other physician. The other
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physician had seen the DMR, but never actually showed the x-rays themselves. That secondary surgeon caused that patient to have a permanent foot drop and partial quarter point of syndrome And
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actually went to that patient post-op, night one, and actually apologized to the patient. Well, this ultimately went to court.
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And that's the problem. You go to court, you don't know what verdict you're going to get. It ended up being a defense verdict. The patient actually came to court and she clearly had a foot drop
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with the neurologist from the defense claiming she didn't have a foot drop. Of course, it was offered in court In fact, I offered an import to examine the patient, take off her shoe and let her
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walk across the room. But that was denied in any case the lessons learned from this case is talk to and examine your patient Preoperatively obtain your informed consent and don't do unnecessary
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fusions without that T-LIF fusion This patient would have remained intact and not had the miserable life that she now has So just in the terms of the background
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for this. This is an illustration of a T-LIF okay, and basically I had Respectively looked at a series of my own patients 58 patients two to three level aminectomies and what were the Neurological
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problems or any other complications or adverse events in these patients. They had no new neurological deficits No infections, no read missions, no re-operations And what I did is I contrasted that
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with what the literature shows for T-LIFs for their adverse events 83 Many show higher numbers than that and I'll show you some of those Okay, inter body graft subsidence that can be one. Okay,
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inter body infection And very importantly, those screws can go all over the place. By the way, in cases like this case where she ended up with a complete foot drop, we don't know if a screw had
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been placed right through the L5 root inadvertently, but then taken out before they replaced it.
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Or was it attraction injury because they were unnecessarily retracting that? They go sack in a very stenotic canal in order to get the inter-body device in place, which she didn't need. So
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here is just a further review. This is an example of a T-LIF. T-LIF risks, 83 infections, derodomies, permanent motor deficits, new sensory deficits, a much lower, less than 5 incidence of
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adverse events being seen otherwise. And here again, classic example of a screw going right across the drill sack and crossing the spinal canal.
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So underreported major vascular injuries are other factors. And here are some of the major vessels that you're seeing anteriorly. So here's an example of screws at the S1 level that could be
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directly heading towards your major vessels and in fact, cause your major life-threatening hematomas.
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Okay, so basically what have we seen in this group of lumbar surgical procedures? Negligent lumbar surgery What's their neurological status and what's their outcomes? Well, here we had the first
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case where the emergency room missed the quarter coin syndrome. But she ended up intact because she ended up being brought back emergently by a friend who happened to be a neurosurgeon. That
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actually was me. And she ended up having emergent surgery and she didn't ever bring a suit. Minimally invasive discectomy, unnecessarily small exposure in a case that obviously warranted bigger
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exposure. the fact that you get a CSF leak within the standard of care, but is it really within the standard of care if you've done the wrong operation? And here I would state that the wrong
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operation was done, but also more importantly, postoperatively, they did not expand the exposure in order to adequately repair the leak, the leak recurred, they ignored that leak postoperatively
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to the point where once later the patient had adhesive arachnoiditis, and yes, it was a home jury, but still that patient deserved better. Affiliated diagnosis and treat corticointed syndromes,
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these patients present with varying degrees of paralysis or complaints. It's a stuttering course. Ultimately, they appear in the emergency rooms with paralysis and sphincter loss and many of these
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cases go on to settle. Affiliated to timely remove and epidural absists and a patient who's basically presenting paraplegic loss bladder and bowel function that might, ready to go, being told, oh
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no. We're just gonna do the surgery tomorrow. That resulted in a huge settlement. And then performing an unnecessary T-LIF, foot drop to the patient, quarter coin syndrome. This ended up being a
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defense verdict. And what was amazing is in this case, this was actually a case where a grievance was brought against me through the American Association of Neurological Surgeons. This patient had
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never been physically spoken to or examined by the surgeon who operated on her using the minimally invasive approach, giving her a complete and permanent foot
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drop. Okay, so, how would you have adjudicated these cases? Is it gonna be a defense verdict, a plaintiff's verdict or a settlement? And more importantly, what errors should you avoid in the
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future for your patients, your family? And certainly if it's you or the patient, yourself. So what to avoid, avoid missing quarter coin syndrome. the MR, not just the CT scan. Avoid having the
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minimally invasive approach done where more exposure may be needed. By the way, get that second opinion. Avoid failing to get the timely diagnosis and treatment for that quarter point of syndrome.
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If your consultant does not seem reasonable, keep looking. Go for that other opinion. Don't give up and don't just go sit home until you just get worse. Avoid failing to emotionally operate on
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paraplegic patients with abscesses, much less quarter point of syndromes or other neurological factors leading to paralysis. Don't send patients home who are paralyzed and avoid unnecessary
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significant fusions in patients who don't need those fusions and don't operate on patients where you have not examined the patient, have never spoken to the patient as in that case. and then operate
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on the patient
26:44
really unnecessarily. So the conclusion is when you're looking at patients, you're going to avoid malpractice suits by doing the right timely operation on the right patient for the right reasons.
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And in this cartoon, the surgeon is rushing the patient to surgery as malpractice specialist, great rates and free quotes You're not going to have significant malpractice cases if you as a surgeon
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have done the right thing. Thank you.
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By the way, there are some other articles that I can show you that are, if you're looking for some of these references, you can look at a cervical operation that's talking about how to treat the
27:33
OPLL frequencies of CSF leaks. for anterior discectomy infusions, usually less than one to two percent, OPLL can be significantly higher than that. And then just talking about synovial cysts and
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how to treat those and surgeon-based outcomes
27:54
and other factors.
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And this is just emphasizing get second opinions because in this series of 180 patients who had second opinions, I was the second opinion, actually 60 needed nothing at all. 33 were being told they
28:10
needed the wrong operation and 6 were told that they were gonna have the right operation. Also, you wanna know is there a company pathology and other factors that you wanna know about? So those are
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some other articles that you can take a look at when you bring this up and review this. We hope you enjoyed this presentation.
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The material provided in this program is for informational purposes and is not intended as use as a diagnosis or treatment of a health problem or as a substitute from seeing a licensed medical
28:51
professional. At the
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end of the video, please fill out your rating on the rating schedule located at the bottom of the program on the website This recorded session is available free on snidigialorg. Send your
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CME to osmondsnidigialorg.
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The foundation supporting these programs believes there are many ways to learn. Two of them are supported by the foundation.
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One is Surgical Neurology International, known as SI. Its web address is SIglobal. It's a 2D internet journal. Nancy Epstein is its editor-in-chief.
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The second journal is a new video Live video journal of neurosurgery, interactive with discussion. Its web address is SIdigitalorg, and it's available 247365 worldwide.
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Surgical Neurology International is read in 239 countries and territories, over a 14-year period of publication And it's the third, most likely, red 2D journal in our surgery.
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and SI digital innovations in learning after 10 months of publication is now in 145 countries as a new 3D video journal. Purpose of the foundation is to help people throughout the world.
30:35
And it also sponsors a medical news network for the purpose of bringing truthful medical and science news into the world
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This program is copyrighted by the James I and Carol in our Ospun Educational Foundation in 2024. All rights are reserved.
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We hope you enjoyed the program. Thank you for being here.
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