Medical Malpractice Claims and Mitigation Strategies Following Spine Surgery

Analysis of reasons for medical malpractice litigation due to anterior cervical discectomy and fusion

Background

Anterior cervical discectomy and fusions (ACDF) are among the most common cervical spine operations, with over 137,000 surgeries performed annually. Understanding reasons underlying malpractice pertaining to ACDF may inform physicians of practices to improve delivery of patient care and mitigate malpractice. The aim of our study was to analyze the causes and outcomes for lawsuits pertaining to ACDF.

Methods

The Westlaw Edge and Verdict Search databases were queried for malpractice claims utilizing the keywords "anterior cervical discectomy and fusion" and "ACDF". Inclusion criteria was based on relevance of case grievance(s) to ACDF. Data collected included date of case hearing, plaintiff demographics, defendant specialty, verdict ruling, location of filed claim, monetary award, and sustained injuries.

Results

Fifty cases were included in this study after excluding 1933 cases. Of the 50 cases, 34 (68%) resulted in a defendant outcome, 8 (16%) resulted in a plaintiff outcome, and 8 (16%) resulted in settlement. Plaintiff verdicts resulted in an average monetary payment of $9.70 million, while settlements resulted in an average payment of $2.06 million. Reasons for litigation were divided into 10 categories, most commonly improper postoperative management (20%), hardware failure (18%), intraoperative error (14%), off-label use of implants (14%), and insufficient informed consent (12%).

Conclusions

Malpractice claims due to ACDF are associated with higher frequencies of plaintiff verdicts and higher monetary costs compared to other spinal surgery procedures. There does not appear to be supporting evidence that spinal cord neuromonitoring is mandatory for ACDF procedures from a medicolegal standpoint.

Epidemiology of the causes of complaints after discectomy collected from a French insurance company

INTRODUCTION

Lumbar discectomy is a frequent procedure performed by surgeons from specialties at risk of patient complaints. The objective of the study was to analyze the causes of litigations following lumbar discectomy to be able to reduce their frequency.

MATERIAL AND METHODS

This observational, retrospective study was carried out at a French insurance company (Branchet). All files opened between the 1st of January 2003 and the 31st of December 2020, following lumbar discectomy without instrumentation and without any other associated code, undertaken by a surgeon insured by Branchet, were analyzed. The data was extracted from the database by a consultant from the insurance company and analyzed by an orthopedic surgeon.

RESULTS

One hundred and forty-four records met all inclusion criteria and were complete and available for analysis. Infection was the leading cause of litigation, responsible for 27% of complaints. Residual postoperative pain was the second cause of complaint with 26% of cases, of which 93% had persistent pain. Neurological deficits were the third cause of complaint with 25% of cases among which 76% were related to the appearance of a deficit and 20% related to the persistence of an existing deficit. Early recurrence of herniated disc also appeared as a cause of complaint, accounting for 7% of cases.

CONCLUSION

Surgical site infection, persistence of pain, and the appearance or persistence of neurological disorders are the primary causes of complaints leading to investigation in the aftermath of lumbar discectomy. It seems essential to us that this information be brought to the attention of surgeons to enable them to better adapt their explanations in the delivery of preoperative information.

LEVEL OF EVIDENCE

IV.

Demographics of Cauda Equina Syndrome: A Population-Based Incidence Study

INTRODUCTION

Cauda equina syndrome (CES) has significant medical, social, and legal consequences. Understanding the number of people presenting with CES and their demographic features is essential for planning healthcare services to ensure timely and appropriate management. We aimed to establish the incidence of CES in a single country and stratify incidence by age, gender, and socioeconomic status. As no consensus clinical definition of CES exists, we compared incidence using different diagnostic criteria.

METHODS

All patients presenting with radiological compression of the cauda equina due to degenerative disc disease and clinical CES requiring emergency surgical decompression during a 1-year period were identified at all centres performing emergency spinal surgery across Scotland. Initial patient identification occurred during the emergency hospital admission, and case ascertainment was checked using ICD-10 diagnostic coding. Clinical information was reviewed, and incidence rates for all demographic and clinical groups were calculated.

RESULTS

We identified 149 patients with CES in 1 year from a total population of 5.4 million, giving a crude incidence of 2.7 (95% CI: 2.3-3.2) per 100,000 per year. CES occurred more commonly in females and in the 30-49 years age range, with an incidence per year of 7.2 (95% CI: 4.7-10.6) per 100,000 females age 30-39. There was no association between CES and socioeconomic status. CES requiring catheterization had an incidence of 1.1 (95% CI: 0.8-1.5) per 100,000 adults per year. The use of ICD-10 codes alone to identify cases gave much higher incidence rates, but was inaccurate, with 55% (117/211) of patients with a new ICD-10 code for CES found not to have CES on clinical notes review.

CONCLUSION

CES occurred more commonly in females and in those between 30 and 49 years and had no association with socioeconomic status. The incidence of CES in Scotland is at least four times higher than previous European estimates of 0.3-0.6 per 100,000 population per year. Incidence varies with clinical diagnostic criteria. To enable comparison of rates of CES across populations, we recommend using standardized clinical and radiological criteria and standardization for population structure.

Why are spine surgeons sued, and with what outcomes?

Background

Why are spine surgeons sued, how successfully, and for how much? Typical bases for spinal medicolegal suits have included; the failure to timely diagnose and treat, surgical negligence, (i.e. especially resulting in significant neurological deficits), and the lack of informed consent. We reviewed 17 medicolegal spinal articles looking for additional reasons for suits, along with identifying other factors contributing to defense verdicts, plaintiffs' verdicts, or settlements.

Methods

After confirming the same three most likely causes of medicolegal suits, other factors leading to such suits included; the lack of patient access to surgeons postoperatively, poor postoperative management (i.e. contributing to new postoperative neurological deficits), failure to communicate between specialists/surgeons perioperatively, and failure to brace.

Results

Critical factors leading to more plaintiffs' verdicts and settlements along with higher payouts for both included new severe and/or catastrophic postoperative neurological deficits. Conversely, defense verdicts were more likely for those with less severe new and/or residual injuries. The total number of plaintiffs' verdicts ranged from 17-35.2%, settlements, from 8.3-37%, and defense verdicts from 27.7-75%.

Conclusion

The three most frequent bases for spinal medicolegal suits continue to include; failure to timely diagnose/treat, surgical negligence, and lack of informed consent. Here, we identified the following additional causes of such suits; the lack of patient access to surgeons perioperatively, poor postoperative management, lack of specialist/surgeon communication, and failure to brace. Further, more plaintiffs' verdicts or settlements and greater respective payouts were observed for those with new and/or more severe/catastrophic deficits, while more defense verdicts were typically rendered for patients with lesser new neurological injuries.

Trends and Contributing Factors in Medicolegal Cases Involving Spine Surgery

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVE

The aim of this study was to describe closed medicolegal cases involving physicians and spine surgery in Canada from a trend and patient safety perspective.

SUMMARY OF BACKGROUND DATA

Spine surgery is a source of medicolegal complaints against surgeons partly owing to the potential severity of associated complications. In previous medicolegal studies, researchers applied a medicolegal lens to their analyses without applying a quality improvement or patient safety lens.

METHODS

The study comprised a 15-year medicolegal trend analysis and a 5-year contributing factors analysis of cases (civil legal and regulatory authority matters) from the Canadian Medical Protective Association (CMPA), representing an estimated 95% of physicians in Canada. Included cases were closed by the CMPA between 2004 and 2018 (trends) or 2014 and 2018 (contributing factors). We fit a linear trend line to the annual rates of spine surgery cases per 1000 physician-years of CMPA membership for physicians in a neurosurgery or orthopedic surgery specialty. We then applied an ANOVA type III sum of squares test to determine the statistical significance of the annualized change rate over time. For the contributing factors analysis, we reported descriptive statistics for patient and physician characteristics, patient harm, and peer expert criticisms in each case.

RESULTS

Our trend analysis included 340 cases. Case rates decreased significantly at an annualized change rate of -4.7% (P  = 0.0017). Our contributing factors analysis included 81 civil legal and 19 regulatory authority cases. Most patients experienced health care-related harm (89/100, 89.0%). Peer experts identified intraoperative injuries (29/89, 32.6%), diagnostic errors (14/89, 15.7%), and wrong site surgeries (16/89, 18.0%) as the top patient safety indicators. The top factor contributing to medicolegal risk was physician clinical decision-making.

CONCLUSION AND RELEVANCE

Although case rates decreased, patient harm was attributable to health care in the majority of recently closed cases. Therefore, crucial opportunities remain to enhance patient safety in spine surgery.Level of Evidence: 4.

The Personal and Professional Impact of Patients' Complaints on Doctors-A Qualitative Approach

Background: Complaints regarding medical practice represent a harsh reality of the current world. Patients have the right to receive explanations and compensation when they are injured during the medical act, but the increased potential for exposure to complaints determines personal and professional consequences for the doctors, with significant impact on their health and practice. Thus, the aim of our research was to analyze in depth the impact of complaints on the doctors involved. Materials and methods: The authors conducted a qualitative study, using a semi-structured interview, addressed to doctors who had complaints from patients. The participants in our research were identified using an adapted version of the snowball method. Results: After the analysis of the interviews using the inductive method, nine themes resulted, seven of which are addressed in this paper: injustice, personal impact, professional impact, difficulties, supportive factors, the attitude of the hospital management and the attitude of colleagues. At the personal level, the doctors were overwhelmed by insomnia, nightmares, stress and anxiety, and at the professional level by doubts about medical decisions, fear, anxiety and the tendency to avoid patients with severe diseases. Conclusions: The study revealed that physicians who had complaints from patients are deeply affected by the complaint itself and the associated investigation procedure, even if, to a lesser extent, some of the participants found motivation for a better management of the situation. The study also showed the need for changes in the legal and medical systems in order to create mechanisms to support the doctors during the investigation process.

The prevalence of medical violation claims and associated predictors at the Eastern Province in Saudi Arabia: A logistic regression analysis

Despite efforts to improve healthcare delivery and ensure patient safety, medicolegal claims in Saudi Arabia remain a concerning issue. This study investigated medical violation claims referred to the medical violation committee in the Eastern Province in Saudi Arabia. A retrospective study was conducted on medical violation claims from 2016 to 2019. Binary logistic regression was performed to examine the association between issued verdicts and a set of defendant, plaintiff and healthcare institution variables. During the study's period, the medical violation committee reached final verdicts against 1242 healthcare professionals in which 69% of them were found guilty. The majority of the defendants worked in private healthcare institutions (66%), were physicians (30%), male (53%), and non-Saudi (64%). Working at pharmacies, other healthcare settings, and the private sector were significantly associated with receiving a guilty verdict. Male healthcare professionals as well as pharmacists were found to have a higher likelihood to receive a guilty verdict than their respective counterparts. Medical violation claims filled by the Ministry of Health were more likely to receive guilty verdicts than those filled by patients or healthcare professionals. Findings of the study extend the literature on medicolegal claims and introduces implications for healthcare professionals and policymakers at institutional and national levels.