Spinal Surgery

Spinal surgery risks

Low back pain is the leading global cause of disability (1). A range of treatments include manual and physical therapies, opioids, non-opioid painkillers, medicinal cannabis, spinal injections, and nerve ablation. Spinal surgery is often sought when these treatments fail, but the benefits must be carefully weighed against the risks.

Increasing rates of surgery

Elective spinal surgery rates have been increasing over the last 20 years in Australia (2), a trend also seen in the US and Europe (3,4,5,6), with the increase disproportionally greater among privately insured patients. During 2012–18, 83% of spine procedures in Australia were performed in the private sector (7).

Suggested reasons for increased spinal surgeries include the ageing population, the advent of newer technologies for performing procedures, the increased availability of imaging, ineffectiveness of other treatments, and surgeon preference (8).

Lack of evidence

A review of the evidence for spinal surgery as a treatment for low back pain found that spinal surgery has a role in alleviating radicular pain and disability resulting from neural compression, or where back pain relates to cancer, infection, or gross instability. However, spinal surgery for all other forms of back pain is unsupported by clinical data, and the broader evidence base for spinal surgery in the management of low back pain is poor and suggests it is ineffective (9). The lack of high-quality evidence for the effectiveness of many spinal procedures (10) means there are no clear clinical practice guidelines, no consensus on the indications for spinal surgery, and considerable practice variation (8).

Adverse outcomes and claims

Negative outcomes for spinal surgery patients can be catastrophic, such as paraplegia, incontinence, and severe and/or chronic pain.

Spinal surgery was the most common type of procedure involved in wrong site surgery, and 60% of neurosurgery malpractice claims involved spinal surgery, in US studies (4). MDA National’s claims data shows that claims related to spinal surgery are costly, with 78% of incurred costs for claims against neurosurgeons from 2005-2019 related to spinal surgery.

Reducing the risk

Common themes in claims and complaints which can be addressed by clinicians are:

• Poor choice of patient or procedure Referrals to surgeons and decisions to operate should be made according to current evidence-based clinical thresholds, for example the Low Back Pain Clinical Care Standard (11), Therapeutic Guidelines (12), or Choosing Wisely (13). Caution is advised in proceeding to surgery for patients with comorbidities, psychological components of chronic pain and on workers compensation (14,15,16).
• Problems with the consent process Patients should be informed about the risks and alternative treatment options, preferably using a procedure-specific consent form and with thorough documentation in the medical record. Surgeons should try to ensure that patients have realistic expectations and are not rushed into providing consent (17,18,19,20).
• Failure to follow standard protocols Protocols should be followed to help with accurate intraoperative localisation, prevention of wrong site surgery, patient positioning that minimises compromise of nerves, and equipment checks (21,22,23,24).
• Delay in recognising complications Recovery room staff, other treating health professionals and patients should be informed about signs and symptoms to be concerned about and how to contact the surgeon urgently if issues arise. Surgeons should be alert to minimising delays in responding to potential complications (25).

This article is provided by MDA National. They recommend that you contact your indemnity provider if you need specific advice in relation to your insurance policy or medico-legal matters. Members can contact MDA National for specific advice on freecall 1800 011 255 or use the “contact us” form at mdanational.com.au.

References

1. Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017; 390:1211–59
2. Tran DT, Lewin AM, Jorm L & Harris IA. Elective spinal surgery in New South Wales adults, 2001-20, by procedure funding type: a cross -sectional study. MJA. Published online: 14 August 2023
3. Grotle M, Småstuen M, Fjeld O, et al. Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019; 9: e028743
4. Martin BI, Mirza SK, Spina N, et al. Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976) 2019; 44: 369‐376
5. Ponkilainen VT, Huttunen TT, Neva MH, et al. National trends in lumbar spine decompression and fusion surgery in Finland, 1997–2018. Acta Orthop 2021; 92: 199‐203
6. Sivasubramaniam V, Patel HC, Ozdemir BA, Papadopoulos MC. Trends in hospital admissions and surgical procedures for degenerative lumbar spine disease in England: a 15‐year time‐series study. BMJ Open. 2015; 5: e009011
7. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The fourth Australian atlas of healthcare variation. Sydney: ACSQHC, 2021
8. Hunt S. Increase in privately funded spinal surgeries prompts questions. Insight+. 2023; 30(14)
9. Evans L, O’Donohoe T, Morokoff A & Drummond K. The role of spinal surgery in the treatment of low back pain. MJA. 2022; 218(1): 40-45
10. Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG; for the Lancet Low Back Pain Series Working Group. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391:2368
11. Australian Commission on Safety and Quality in Health Care. Low back pain clinical care standard. 2022.
12. https://www.tg.org.au/
13. https://www.choosingwisely.org.au/
14. Pham C, Gibb C, Field J, et al. Managing high-risk surgical patients: modifiable co-morbidities matter. ANZ J Surg. 2014; 84: 925–931
15. Atkinson L & Zacest A. Surgical management of low back pain. MJA. 2016, 204(8):299-300
16. Harris IA, Dantanarayana N & Naylor JM. Spine surgery outcomes in a workers’ compensation cohort. ANZ J Surg. 2001;82:625-629
17. McGregor AH, Hughes SP. The evaluation of the surgical management of nerve root compression in patients with low back pain. Part 2. Patient expectations and satisfaction. Spine 2002;27:1471–6; discussion 6–7
18. Grauberger J et al. Allegations of failure to obtain informed consent in spinal surgery medical malpractice claims. JAMA Surg. 2017; 152(6):e170544
19. Bhattacharyya T, Yeon H & Harris MB. The Medical-Legal Aspects of Informed Consent in Orthopaedic Surgery. J Bone Joint Surg Am, 2005; 87(11):2395-400
20. Barritt AW, Clark L, Teoh V, Cohen AMM & Gibb PA. Assessing the adequacy of procedure-specific consent forms in orthopaedic surgery against current methods of operative consent. Ann R Coll Surg Engl. 2010; 92(3):246-9
21. Hsu W, Kretzer RM Dorsi MJ & Gokaslan ZL. Strategies to Avoid Wrong-site Surgery During Spinal Procedures. Neurosurg Focus. 2011;31(4):e5
22. de Loubresse CG. Neurological risks in scheduled spinal surgery. Orthopaedics & Traumatology: Surgery & Research 2014 100: S85-S90
23. Weerakkody RA et al Surgical technology and operating-room safety failures: a systematic review of quantitative studies. BMJ Qual Saf 2013; 22:710-718
24. De Vries EN, Eikens-Jansen MP, Hamersma AM et al. Prevention of surgical malpractice claims by use of a surgical safety checklist. Ann Surg. 2011; 253:624-628
25. Daniels AH et al Malpractice litigation following spine surgery. J Neurosurg Spine 2017; 27:470-475