Malpractice litigation in elective lumbar spinal fusion: a comprehensive review of reported legal claims in the U.S. in the past 50 years

BACKGROUND CONTEXTIn the U.S., medical malpractice litigation is associated with significant financial costs and often leads to the practice of defensive medicine. Among medical subspecialities, spine surgery is disproportionately impacted by malpractice claims.PURPOSETo provide a comprehensive assessment of reported malpractice litigation claims involving elective lumbar spinal fusion (LSF) surgery during the modern era of spine surgery instrumentation in the U.S., to identify factors associated with verdict outcomes, and to compare malpractice claims characteristics between different approaches for LSF.STUDY DESIGN/SETTINGA retrospective review.PATIENT SAMPLEPatients undergoing elective lumbar spinal fusion surgery.OUTCOME MEASURESThe primary outcome measure was verdict outcome (defendant vs. plaintiff verdict). Secondary outcome measures included alleged malpractice, injury/damage claimed, and award payouts.METHODSThe Westlaw legal database (Thomson Reuters, New York, NY, USA) was queried for verdict and settlement reports pertaining to elective LSF cases from 1970 to 2021. Data were collected regarding patient demographics, surgeon specialty, fellowship training, state/region, procedure, institutional setting (academic vs. community hospital), alleged malpractice, injury sustained, case outcomes, and monetary award.RESULTSA total of 310 cases were identified, yielding 67% (n=181) defendant and 24% (n=65) plaintiff verdicts, with 9% (n=26) settlements. Neurosurgeons and orthopedic spine surgeons were equally named as the defendant (45% vs. 51% respectively, p=0.59). When adjusted for inflation, the median final award for plaintiff verdicts was $1,241,286 (95% CI: $884,850–$2,311,706) while the median settlement award was $925,000 (95% CI: $574,800–$1,787,130), with no stastistically significant differences between verdict and reported settlement payouts (p=0.49). The Northeast region displayed significantly higher award payouts compared to other U.S. regions (p=0.02). There were no associations in awards outcomes when comparing alleged malpractice, alleged injuries/damages, institutional setting, surgical procedures, and surgeon specialty or fellowship training. The most common claims were intraoperative error (28%, n=107) followed by failure to obtain informed consent (24%, n=94). In the analyzed cohort, the most common injuries leading to litigation were refractory pain and suffering (37%, n=149) followed by permanent neurological deficits (26%, n=106). There were no differences in alleged malpractice or injury sustained between cases in which the outcome was favorable to defendant versus plaintiff. Anterior lumbar interbody fusion (ALIF) cases were 2.75 times more likely to be cited for excessive or inappropriate surgery (OR: 2.75 [95% CI: 1.14, 6.86], p=0.02) when compared to posterior surgical approaches.CONCLUSIONThe results of our analysis of reported claims suggest that medical malpractice litigation involving elective LSF is associated with jury verdicts over $1 million per case, with the most common alleged malpractice being intraoperative error and failure to obtain informed consent. Surgeon specialty, fellowship training, procedure type, and institution type were not associated with greater litigation risks; however, ALIF surgery had a significantly higher risk of involving claims of excessive or inappropriate surgery compared to posterior approaches for lumbar fusion. In addition, claims were significantly higher in the Northeast compared to other U.S. regions. Efforts to improve patient education through shared-decision making and proactive strategies to avoid, detect, and mitigate intra-operative procedural errors may decrease the risk of litigation in elective LSF.     

Nuances of otoplasty: a comprehensive review of the past 20 years

Otoplasty for the correction of the prominent ear is a heavily debated topic in Facial Plastic Surgery. This article presents the past 20 years of literature on the topic in a concise and organized manner. The greatest area of focus is on the finer nuances between cartilage-sparing and cartilage-incising techniques. In addition, some of the latest research on anesthesia techniques, nonoperative approaches, and social issues are discussed.     

Epidemiology of pediatric spinal cord injury in the United States: years 1997 and 2000

PURPOSE: The purpose of this study is to report the current incidence rates of pediatric spinal cord injury (SCI) in the United States and identify specific high-risk populations as a knowledge basis for improving the prevention and treatment of this traumatic injury. METHODS: The Kids' Inpatient Database (KID) and the National Trauma Data Bank (NTDB) were used to investigate the etiology of pediatric SCI. RESULTS: Significant differences in the annual incidence rate of pediatric SCI were found to exist between patient populations stratified by race and sex. African Americans (1.53 cases/100,000 children) exhibit a significantly higher rate of pediatric SCI than native Americans (1.00), Hispanics (0.87), and Asians (0.36), whereas Asians show a significantly lower incidence than all other races. Also, boys (2.79) are more than twice as likely to experience SCI as girls (1.15). The overall incidence of pediatric SCI in the United States is 1.99 cases per 100,000 children. From these data, it is estimated that 1455 children are admitted to US hospitals each year for treatment of SCI. The etiology of pediatric SCI was also investigated, and the major causative factors were identified: motor vehicle accident (56%), accidental fall (14%), firearm injury (9%), and sports injury (7%). Of those children injured in a motor vehicle accident, 67.7% (n = 107) were reported as not wearing a seatbelt. The role of alcohol and drugs was also investigated and found to be involved in 30% (n = 82) of all pediatric SCI cases. CONCLUSIONS: Using discharge records from a public database, it is possible to identify high-risk demographic groups and activities that predispose a child to SCI. With a more thorough understanding of the etiology of pediatric SCI, clinicians and parents are better equipped to devise measures for prevention and treatment of this injury.     

Hepatitis B virus: a comprehensive strategy for eliminating transmission in the United States

There is a global epidemic of hepatitis B virus (HBV) infections affecting more than 350 million people worldwide. This collective review provides the rationale for a comprehensive strategy to eliminate transmission of HBV in the United States.The virologic characteristics of HBV include three forms of HBV surface antigen (HBsAg), HBV core antigen (HbcAg), as well as a circulating peptide, the HBV e antigen (HBeAg). The year 2002 was the 20th anniversary of the use in the United States of the world's first vaccine against HBV. Our prevention strategy involves making HBV vaccine a part of the routine vaccination schedules for all infants in the United States. Hepatitis B immune globulin (HBIG) is another useful adjunct for prophylaxis that provides temporary protection (i.e., 3-6 months) and is recommended in only certain postexposure settings. The routes for administration of HBV vaccine and HBIG are intramuscular sites that differ according to the age of the individual. Following routine HBV vaccination in adults and children, prevaccination and postvaccination serologic testing is not recommended because of the relatively low rate of HBV infection and the low cost of the vaccine. Postexposure prophylaxis for HBV with serologic testing is, however, necessary for all hospital personnel exposed to blood or body fluids. In addition, infants born from mothers not immunized to HBV or those who are infected with HBV also require comprehensive postexposure prophylaxis with serologic testing. Comprehensive immunization strategies with serologic testing must be implemented for all groups that have a high risk of HBV infection. Finally, vaccine information statements (VIS) must be carefully integrated in this comprehensive disease prevention strategy, which is designed to prevent the transmission of HBV in the United States.     

Microsurgery in otology and laryngology: a review of developments during the past thirty years

The operating microscope was originally introduced to provide better visualization and illumination for otologic surgery. The successful use of this instrument in the fenestration operation for otosclerosis rapidly led to its application to reconstructive procedures in chronic suppurative otitis media. Later, it became evident that the operating microscope also provided advantages in the treatment of inner ear disorders and in the removal of acoustic Schwannomas; a considerable reduction in morbidity and an improved prognosis have resulted from application of microsurgery to these conditions. In addition, new photographic and television equipment, used in combination with microsurgery, has greatly improved the standards of teaching and the recording of pathologic information.     

Variation in the management of pediatric splenic injuries in the United States

BACKGROUND: This study examines the existence and sources of variation in the management of pediatric splenic injuries among hospitals in the United States and the factors associated with splenectomy. METHODS: Information on children 15 years of age and younger with a splenic injury diagnosis code was extracted from the Kids' Inpatient Database 2000, a pediatric inpatient database of 2,784 hospitals in 27 states covering 72% of the nation's population for the year 2000. Patient variables included age, sex, race, injury diagnoses, grade of splenic injury, splenic procedure code, and calculated Injury Severity Score. Hospital variables included pediatric status (free-standing, unit and adult), teaching status, annual pediatric splenic trauma volume, and national region. A multivariate logistic regression model was used to predict the factors associated with splenectomy based upon patient and hospital characteristics. RESULTS: In all, 2,191 children with splenic injuries were identified; 253 (12%) underwent splenectomy. The crude rate of splenectomy varied significantly among pediatric hospital types: 3% (11/339) at freestanding children's hospitals, 9% (45/525) at unit hospitals and 15% (197/1327) at adult hospitals (p < 0.001). Risk of splenectomy increased with the grade of splenic injury, patient age, and the presence of multiple injuries. Teaching hospitals and hospitals with higher patient volume were associated with lower risk for splenectomy. There was no relationship between splenectomy and gender, race, or national region. Despite adjustment for the above noted hospital and patient-specific variables, children treated at an adult hospital had 2.8 times the odds, and those treated at a unit pediatric hospital 2.6 times the odds, of undergoing splenectomy as those cared for at a free-standing pediatric hospital (p = 0.003 and 0.013, respectively). CONCLUSION: Nationally, children cared for at freestanding pediatric hospitals have a significantly lower risk of splenectomy than children treated at either adult hospitals or pediatric hospitals within an adult hospital. This may have implications for education, trauma triage and the establishment of practice guidelines.     

骨科感染病原菌谱与抗菌谱3年报告

[目的]了解骨科病人所感染菌群及其耐药性,指导临床正确应用抗生素。[方法]对骨科门诊及病房细菌感染病人的708份分泌物、脓液等标本进行需氧培养,并对检出菌按K-B法做体外药敏实验。[结果]检出致病菌259株,G 菌占47.9%,其中金黄色葡萄球菌33.0%,凝固酶阴性葡萄球菌14.9%;G-菌占52.1%,其中假单胞菌属占7.3%,不动杆菌属占6.1%。药敏显示革兰阳性球菌对青霉素及苯唑青霉素的耐药率逐年升高,对万古霉素的敏感性最高为100%。革兰阴性杆菌对亚胺培南的敏感率最高,3年平均95.8%,对头孢他啶也较敏感,但有逐年下降的趋势,对环丙沙星、阿米卡星、哌拉西林的耐药率较高,分别为46.0%、47.0%、51.2%。[结论]骨科病人感染的病原菌中,G-杆菌占大多数且有上升趋势,G 球菌感染发生率少于G-杆菌,单菌株以金黄色葡萄球菌占首位。对G-球菌可以选用万古霉素、苯唑青霉素、诺氟沙星等;对G-杆菌可以选用亚胺培南、头孢他啶。革兰阴性杆菌引起骨科感染有上升趋势,耐药也较严重,加强感染菌及药敏检测,合理使用抗生素非常必要。     

骨髓间充质干细胞治疗脊髓损伤的研究进展

<正>骨髓间充质干细胞(bone marrow mesenchymal stem cells,BMSCs)因具有取材方便、能够自体移植、无免疫源性、不受伦理学限制等特征成为治疗脊髓损伤的种子细胞之一[1、2],BMSCs治疗脊髓损伤的机制主要有分化为神经样细胞、抑制炎症反应、神经营养作用及促进轴突再生[3、4]。早期临床实验表明BMSCs移植治疗脊髓损伤安全、有一定疗效[5]。笔者针对目前BMSCs治疗脊髓损伤中的出现新观     

Time trends in reported prevalence of kidney stones in the United States: 1976-1994

BACKGROUND: A body of evidence establishes that the occurrence of kidney stone disease has increased in some communities of industrialized countries. Information on recent temporal trends in the United States is lacking and population-based data on epidemiologic patterns are limited. Study objective was to determine whether kidney stone disease prevalence increased in the United States over a 20-year period and the influence of region, race/ethnicity, and gender on stone disease risk. METHODS: We measured the prevalence of kidney stone disease history from the United States National Health and Nutrition Examination Survey (II and III), population-based, cross-sectional studies, involving 15,364 adult United States residents in 1976 to 1980 and 16,115 adult United States residents in 1988 to 1994. RESULTS: Disease prevalence among 20- to 74-year-old United States residents was greater in 1988 to 1994 than in 1976 to 1980 (5.2% vs. 3.8%, P < 0.05), greater in males than females, and increased with age in each time period. Among 1988 to 1994 adults, non-Hispanic African Americans had reduced risk of disease compared to non-Hispanic Caucasians (1.7% vs. 5.9%, P < 0.05), and Mexican Americans (1.7% vs. 2.6%, P < 0.05). Also, age-adjusted prevalence was highest in the South (6.6%) and lowest in the West (3.3%). Findings were consistent across gender and multivariate adjusted odds ratios for stone disease history, including all demographic variables, as well as diuretic use, tea or coffee consumption, and dietary intake of calcium, protein, and fat did not materially change the results. CONCLUSION: Prevalence of kidney stone disease history in the United States population increased between 1980 and 1994. A history of stone disease was strongly associated with race/ethnicity and region of residence.     

Spinal injuries in the pediatric age group: a review of 82 cases of spinal cord and vertebral column injuries

A review of 82 children with spinal cord and/or vertebral column injury treated in our department between 1968 and 1993 showed that 67% of the patients were boys and the average age was 11.4 years. The cause, vertebral level, and type of injury, and the severity of neurological injury varied with the age of the patient. The cause of pediatric injuries differed from that of adult injuries in that falls were the most common causative factor (56%) followed by vehicular accidents (23%). The most frequent level of spinal injury was in the cervical region (57%, 47 patients) followed by the lumbar region (16.5%, 13 patients). In our series, 18% of the patients had complete injury and the overall mortality rate was 3.6%. Eleven children (13%) had spinal cord injury without radiographic abnormality (SCIWORA), whereas 39 (47%) had evidence of neurological injury. Although the spinal injury patterns differed between children and adolescents, the outcome was found to be predominantly affected by the type of neurological injury (P<0.05). Children with complete myelopathy uniformly remained with severe neurological dysfunction; children with incomplete myelopathy recovered nearly normal neurological function. Finally, the authors conclude that most spinal injuries can be successfuly managed with nonoperative therapy. The literature is reviewed as to the treatment and outcome of pediatric spinal injuries.     

Fourteen years of litigation claims in cardiothoracic surgery in the United Kingdom National Health Service

Approximately 36 400 cardiac and 23 100 thoracic operations are carried out in the United Kingdom between 2006 and 2015. National Health Service (NHS) resolution, as known as the NHS litigation authority, is one of the essential bodies of the Department of Health. Its purpose is to provide NHS expertise to resolve concerns fair and square share learning for improvement. We aim to evaluate and increase awareness of medicolegal cases in cardiothoracic surgery. Total numbers and details of claims coded by NHS resolution in cardiothoracic surgery from 2004 to 2017 were requested under the Freedom of Information Act 2000. The data provided in successful claims is further breakdown into damages paid to the claimant, defence cost, claimant cost paid and the sum of the three. In contrast, unsuccessful claims only include the defence cost. Moreover, data provided also includes further analysis of primary causes and primary injuries for Claims Closed/Settled with damages paid. There were 753 claims recorded from 2004 to 2017, of which 415 (55.11%) were successful. The number of claims has been steadily increasing since 2004, with two significant raises from 2009/10 to 2010/11 (37‐55, 48.64% raise) and 2012/13 to 2013/14 (49‐69, 40.82% raise). The mean successful claim ratio was 69.58% (range, 47.56%‐ 83.33%) There is also a steady increase in the successful ratio from 2004 to 2017. In summary, this is the first study published in relation to litigation claims on cardiothoracic surgery in the United Kingdom. The results have provided insight on claims made against cardiothoracic surgery.