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.     

A nine-year review of medicolegal claims in neurosurgery

Introduction

Neurosurgery remains among the highest malpractice risk specialties. This study aimed to identify areas in neurosurgery associated with litigation, attendant causes and costs.

Methods

Retrospective analysis was conducted of 42 closed litigation cases treated by neurosurgeons at one hospital between March 2004 and March 2013. Data included clinical event, timing and reason for claim, operative course and legal outcome.

Results

Twenty-nine claims were defended out of court and twelve were settled out of court. One case required court attendance and was defended. Of the 42 claims, 28, 13 and 1 related to spinal (0.3% of caseload), cranial (0.1% of caseload) and peripheral nerve (0.07% of caseload) surgery respectively. The most common causes of claims were faulty surgical technique (43%), delayed diagnosis/misdiagnosis (17%), lack of information (14%) and delayed treatment (12%), with a likelihood of success of 39%, 29%, 17% and 20% respectively. The highest median payouts were for claims against faulty surgical technique (£230,000) and delayed diagnosis/misdiagnosis (£212,650). The mean delay between clinical event and claim was 664 days.

Conclusions

Spinal surgery carries the highest litigation risk versus cranial and peripheral nerve surgery. Claims are most commonly against faulty surgical technique and delayed diagnosis/misdiagnosis, which have the highest success rates and payouts. In spinal surgery, the most common cause of claims is faulty surgical technique. In cranial surgery, the most common cause is lack of information. Claims may occur years after the clinical event, necessitating thorough contemporaneous documentation for adequate future defence. We emphasise thorough patient consultation and meticulous surgical technique to minimise litigation in neurosurgical practice.     

Cervical spinal stenosis and sports-related cervical cord neurapraxia in children.

STUDY DESIGN: Congenital spinal stenosis has been demonstrated to contribute to cervical cord neurapraxia after cervical spinal cord injury in adult athletes. A sagittal canal diameter <14 mm and/or a Torg ratio (sagittal diameter of the spinal canal: midcervical sagittal vertebral body diameter) of <0.8 are indicative of significant cervical spinal stenosis. Although sports-related cervical spine injuries are common in children, the role of congenital cervical stenosis in the etiology of these injuries remains unclear. OBJECTIVES: The authors measured the sagittal canal diameter and the Torg ratio in children presenting with cervical cord neurapraxia resulting from sports-related cervical spinal cord injuries to determine the presence of congenital spinal stenosis. METHODS: A total of 13 children (9 male, 4 female) presented with cervical cord neurapraxia after a sports-related cervical spinal cord injury. Age ranged from 7 to 15 years (mean +/- SD, 11.5 +/- 2.7 years). The sports involved were football (n = 4), wrestling (n = 2), hockey (n = 2), and soccer, gymnastics, baseball, kickball, and pogosticking (n = 1 each). Lateral cervical spine radiographs were used to determine the sagittal canal diameter and the Torg ratio at C4. RESULTS: The sagittal canal diameter (mean +/- SD, 17.58 +/- 1.63 mm) and the Torg ratio (mean +/- SD, 1.20 +/- 0.24) were normal in all of these children. CONCLUSION: Using the sagittal canal diameter and the Torg ratio as a measurement of congenital spinal stenosis, the authors did not find evidence of congenital cervical spinal stenosis in a group of children with sports-related cervical spinal cord neurapraxia. The occurrence of cervical cord neurapraxia in pediatric patients can be attributed to the mobility of the pediatric spine rather than to congenital cervical spinal stenosis.     

Neck pain in multisport athletes

OBJECT: The sport of triathlon is very physically demanding and has experienced rapid growth in recent years. The number of triathletes seen for spine disorders at neurosurgery clinics is increasing. Neck pain and overuse injuries have not been adequately studied in multisport athletes. The authors undertook an epidemiological study to establish the lifetime incidence of neck pain and the prevalence of possible discogenic pain, and to identify risk factors among triathletes in the Boulder, Colorado area. METHODS: An online questionnaire was developed to collect information about physical characteristics, training habits, athletic status, number of races completed, and neck pain among triathletes. The incidence of possible cervical discogenic pain was defined according to the duration of symptoms for the most recent pain episode. RESULTS: One hundred and sixty-four athletes responded to the questionnaire. The lifetime incidence of neck pain was 47.6% (78 athletes), with 15.4% possibly being of discogenic origin based on the duration of symptoms. Approximately 64% of responding athletes reported that their neck pain was sports related. Although the number of previous triathlons was not predictive of neck pain, total years in the sport (p = 0.029) and number of previous sports-related injuries (p < 0.0001) were. CONCLUSIONS: Two major risk factors for long-term spinal problems in triathletes are sports-related injuries and overuse. This report is one of the first comprehensive studies of neck pain and overuse injury in multisport athletes.     

Epidemiological profile of sports-related knee injuries in northern India: An observational study at a tertiary care centre

BackgroundSports-related knee injuries occur commonly in athletes. However, there is no published epidemiological study from India till date.ObjectivesThe purpose of this study was to identify common injuries sustained by Indian athletes participating in different sports and to study various associated demographic features. A secondary objective was to investigate different factors, which may affect return to sport by the athlete.Study designCross-sectional study (observational study).Study centreSports injury clinic, PGIMER, Chandigarh.MethodsOut of 465 athletes who presented to us with sports-related knee injuries over a 5-year period, 363 athletes (from 24 different sports) with complete records were identified. Data were analysed for demographic features, type of sport, mechanism of injury, injury scenario, athlete's level of play, injury duration at presentation, injury patterns and type of management. Telephonic interviews were conducted with each athlete to enquire about return to sport and time lost in sport due to the knee injury. Factors associated with return to sport were investigated using statistical tests of association.ResultsSoccer was found to be the most common sport associated with knee injuries accounting for 30.6% of the injuries followed by kabaddi (20.9%). The most common mechanism was non-contact injury (64.4%). Competitive injuries were found to be significantly more than practice/training injuries (p < 0.0001). The most common injuries noted were ACL tears (n = 314) followed by meniscus injuries (n = 284) and the most common combination of injuries were an ACL tear with medial meniscus tear (n = 163). Only 39.8% of the athletes returned to sport. Mean duration of time lost in sport among those who returned to sport was 8.84 months. Return to sport was significantly associated with body mass index, level of competitiveness of the athlete and type of management (p = 0.017, 0.045 and <0.0001, respectively).ConclusionKnee injuries take a huge toll on an athlete's career as observed in this study. Prevention of knee injuries is of paramount importance and more focussed epidemiological studies are needed for formulating policies to prevent sports injuries in both professional and amateur athletes.Level of evidenceIV.     

Influence of Sport Participation on Community Integration and Quality of Life: A Comparison Between Sport Participants and Non-Sport Participants With Spinal Cord Injury

Background/Objective: To determine whether community integration and/or quality of life (QoL) among people living with chronic spinal cord injury (SCI) are superior among sport participants vs non-sport participants.

Study Design: Cross-sectional study.

Participants/Methods: Persons (n = 90) living in the community with SCI (ASIA Impairment Scale A-D), level C5 or below, > 15 years of age, ≥ 12 months postinjury, and requiring a wheelchair for > 1 hours/day were divided into 2 groups based on their self-reported sport participation at interview: sport participants (n = 45) and non-sport participants (n = 45).

Results: Independent-sample t tests revealed that both Community Integration Questionnaire (CIQ) and Reintegration to Normal Living Index (RNL) total mean scores were higher among sport participants vs nonsport participants (P < 0.05). Significant correlation between CIQ and RNL total scores was found for all participants (Pearson correlation coefficients, P < 0.01). Logistic regression analysis revealed that the unadjusted odds ratio of a high CIQ mean score was 4.75 (95% Cl 1.7, 13.5) among current sport participants. Similarly, the unadjusted odds ratio of a high RNL score was 7.00 (95% Cl 2.3, 21.0) among current sport participants. Regression-adjusted odds ratios of high CIQ and high RNL scores were 1.36 (95% Cl 0.09, 1.45) and 0.15 (95% Cl 0.04, 0.55), respectively. The odds ratio for pre-SCI sport participation predicting post-SCI sport participation was 3.06 (95% Cl 1.23, 7.65).

Conclusions: CIQ and QoL scores were higher among sport participants compared to non-sport participants. There was an association between mean CIQ and RNL scores for both groups. Sport participants were 4.75 and 7.00 times as likely to have high CIQ and QoL scores. Both groups had a similar likelihood of high CIQ and RNL scores after adjusting for important confounders. Individuals who participated in sports prior to SCI were more likely to participate in sports post-SCI.     

Military penetrating spine injuries compared with blunt

Background contextThe nature of blunt and penetrating injuries to the spine and spinal column in a military combat setting has been poorly documented in the literature. To date, no study has attempted to characterize and compare blunt and penetrating spine injuries sustained by American servicemembers.PurposeThe purpose of this study was to compare the military penetrating spine injuries with blunt spine injuries in the current military conflicts.Study design/settingRetrospective study.Patient sampleAll American military servicemembers who have been injured while deployed in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) whose medical data have been entered into the Joint Theater Trauma Registry (JTTR).MethodsThe JTTR was queried for all American servicemembers sustaining an injury to the spinal column or spinal cord while deployed in Iraq or Afghanistan. These data were manually reviewed for relevant information regarding demographics, mechanism of injury, surgical intervention, and neurologic injury.ResultsA total of 598 servicemembers sustained injuries to the spine or spinal cord. Isolated blunt injuries were recorded in 396 (66%) servicemembers and 165 (28%) sustained isolating penetrating injuries. Thirty servicemembers (5%) sustained combined blunt and penetrating injuries to the spine. The most commonly documented injuries were transverse process fractures, compression fractures, and burst fractures in the blunt-injured servicemembers versus transverse process fractures, lamina fractures, and spinous process fractures in those injured with a penetrating injury. One hundred four (17%) servicemembers sustained spinal cord injuries, comprising 10% of blunt injuries and 38% of penetrating injuries (p<.0001). Twenty-eight percent (28%) of blunt-injured servicemembers underwent a surgical procedure compared with 41% of those injured by penetrating mechanisms (p=.4). Sixty percent (n=12/20) of blunt-injured servicemembers experienced a neurologic improvement after surgical intervention at follow-up compared with 43% of servicemembers (n=10/23) who underwent a surgical intervention after a penetrating trauma (p=.28). Explosions accounted for 58% of blunt injuries and 47% of penetrating injuries, whereas motor vehicle collisions accounted for 40% of blunt injuries and 2% of penetrating injuries. Concomitant injuries to the abdomen, chest, and head were common in both groups.ConclusionsBlunt and penetrating injuries to the spinal column and spinal cord occur frequently in the current conflicts in Iraq and Afghanistan. Penetrating injuries result in significantly higher rates of spinal cord injury and trend toward increased rates of operative interventions and decreased neurologic improvement at follow-up.     

Injuries sustained in noncombat motor vehicle accidents during Operation Iraqi Freedom

ObjectiveTo examine injuries sustained in noncombat motor vehicle accidents (MVAs) during Operation Iraqi Freedom by injury type, site, and severity.MethodsThree hundred and forty-eight military personnel injured in noncombat MVAs from March 2004-June 2007 were identified from clinical records completed near the point of injury.ResultsOn average, personnel suffered two injuries per accident. The most frequent MVA mechanism was non-collision due to loss of control (30%). Overall, 16% were injured in a collision accident and 19% in a rollover accident. Rollovers were associated with more severe injuries. A greater proportion of drivers sustained head/neck/face injuries, whereas gunners and pedestrians had higher percents of extremity injuries.ConclusionsThis analysis provides a thorough overview of injuries incurred in nonbattle MVAs in the combat environment. Future research should combine injury data with accident reports to elucidate areas for improvements in vehicle safety.     

Litigation following groin hernia repair in England

Purpose

Since 1995, litigation following surgical procedures has cost the National Health Service (NHS) over 1.3 billion GBP (Great British Pounds)/2.1 billion USD (United States Dollars)/1.4 billion Euros. Despite it being the most commonly undertaken general surgical operation, no study has examined clinical negligence claims in England following groin hernia repairs.

Methods

Data from the NHS Litigation Authority of all claims made from 1995 to 2009 was obtained and interrogated.

Results

In total, 398 claims were made. Of these, 209 cases had been settled, of which 144 (46.6%) were in favour of the claimant to a cost of 7.35 million GBP/12 million USD/7.93 million Euros. Testicular injury and chronic pain featured in 40% of all claims. Visceral injuries and injuries requiring corrective procedures were the only predictors of a successful claim (P = 0.015 and P = 0.002, respectively). Claims associated with visceral and vascular injuries were more likely to occur in laparoscopic than in open repairs. Sexual dysfunction and chronic pain resulted in the highest average payouts of 85,467 GBP/140,565 USD/92,177 Euros and 81,288 GBP/133,693 USD/87,674 Euros, respectively.

Conclusion

Patients should be fully informed of the incidence of testicular injury and chronic pain during the consent process. Approaches minimising visceral and vascular injury particularly in laparoscopic repair should be adopted to reduce litigation and improve patient care.     

Relationship of the character of rod fractures on outcomes following long thoracolumbar fusion to the sacrum for adult spinal deformity

BACKGROUND CONTEXTRod fractures (RF) and pseudarthrosis are a frequent occurrence after adult spinal deformity (ASD) surgery and may be problematic. However, not all RF signal nonunion and cause clinical concern. An improved understanding of the sequelae after RF occurrence is valuable for further management.PURPOSETo characterize the radiographic findings, clinical outcomes, and revision rates between patients who developed unilateral RF (URF) and bilateral RF (BRF) following thoracolumbar posterior spinal fusions to the sacrum for ASD and identify patient characteristics associated with clinically significant RF that lead to subsequent revision surgeries and detection of nonunion.STUDY DESIGN/SETTINGA retrospective single-center cohort study was performed.PATIENT SAMPLEPatients undergoing long-construct posterior spinal fusions to the sacrum performed at a single institution from 2004 to 2014 and developed a RF postoperatively were included.OUTCOME MEASURESPatient demographics, radiographic parameters, surgical data, Oswestry Disability Index (ODI), Scoliosis Research Society-22 (SRS-22), and revision rates.METHODSInclusion criteria were ASD patients age >18 who had ≥5 vertebrae instrumented and fused posteriorly to the sacrum and development of RF. Data were compared among patients: who developed unilateral-nondisplaced RF (UNRF), unilateral-displaced RF (UDRF), bilateral-nondisplaced RF and bilateral-displaced RF (BDRF) at baseline and follow-up. ODI and SRS-22 scores were assessed at baseline, 1 year postoperatively, the time of RF occurrence, and latest follow-up.RESULTSOf 526 patients who met inclusion criteria, 96 (18.3%) developed RF (URF n=70 [73%]; BRF n=26 [27%]). Preoperative demographics and surgical parameters were similar between the groups. BRF patients had substantial loss of sagittal correction from 1-year postoperatively to the time of RF, including loss of sagittal vertical axis (4.8 cm vs. 2.2 cm; p<.001), loss of lumbar lordosis (14.8° vs. 4.9°; p=.010) and loss of pelvic incidence minus lumbar lordosis mismatch (PI-LL) mismatch (5.0° vs. 14.6°; p=.020) compared with those of URF patients. The BDRF group had more loss of ODI scores (13.4 vs. 4.2; p=.013), SRS pain score (0.8 vs. 0.2; p=.024), SRS function score (0.3 vs. 0; p=.020) and SRS subscore (0.4 vs. 0.1; p=.148) from 1-year postoperatively to the time of RF and underwent revision surgery more often than the UNRF group (87.5% vs. 4.8%; p<.0001). At final follow-up (median 2.8 years, range 1–10.3 years after RF detection), URF patients who did not undergo revision surgeries still maintained equivalent sagittal alignment correction (sagittal vertical axis, LL and PI-LL; all p>.05) and had similar, not worse, mean ODI scores, SRS Subscore and SRS pain compared with the time at RF and 1-year follow-up.CONCLUSIONSRF are not uncommon after ASD operations. Asymptomatic, UNRF in our study did not jeopardize clinical outcomes or radiographic alignment parameters and, in most cases, did not represent a nonunion, as opposed to BRF. BRF patients exhibited loss of sagittal correction, loss of clinical outcome improvements, as measured by ODI, SRS pain and SRS Subscore at the time of RF, and were revised more often than URF patients.     

Trends in sport and active recreation injuries resulting in major trauma or death in adults in Victoria, Australia, 2001-2007

BackgroundThe purpose of this study was to describe patterns and rates of sport and active recreation injuries that result in major trauma or death and to examine trends in these rates for all sport and active recreation activities and key sporting groups, for the period July 2001–June 2007, in Victoria, Australia.MethodsAll sport and active recreation related major trauma cases and deaths were extracted from the Victorian State Trauma Registry (VSTR) and the National Coroners Information System, for the period July 2001–June 2007. Participation data from the Exercise Recreation and Sports Survey (ERASS) was used to establish incidence rates for the group as a whole and for key sporting groups. Poisson regression analysis was used to examine trends in major trauma and death due to participation in sport and active recreation across the six year study period.ResultsThere were 1019 non-fatal major trauma cases and 218 deaths. The rate of major trauma or death from sport and active recreation injuries was 6.3 per 100,000 participants per year. There was an average annual increase of 10% per year in the major trauma rate (including deaths) across the study period, for the group as a whole (IRR 1.10, 95% CI, 1.06–1.14). There was no increase in the death rate (IRR = 0.94, 95% CI, 0.87–1.02; p = 0.12). Significant increases were also found for cycling (IRR 1.16, 95% CI, 1.09–1.24) off-road motor sports (IRR 1.10, 95% CI, 1.03–1.19), Australian football (IRR 1.21, 95% CI, 1.03–1.42) and swimming (IRR 1.16, 95% CI, 1.004–1.33).ConclusionThe rate of major trauma inclusive of deaths, due to participation in sport and active recreation has increased over recent years, in Victoria, Australia. Much of this increase can be attributed to cycling, off-road motor sports, Australian football and to a lesser extent swimming, highlighting the need for co-ordinated injury prevention in these areas.     

Pathomechanism and prevention of further surgery after posterior decompression for lumbar spinal canal stenosis in patients with diffuse idiopathic skeletal hyperostosis

BACKGROUND CONTEXTDiffuse idiopathic skeletal hyperostosis (DISH) is a risk factor for further surgery after posterior decompression without fusion for patients with lumbar spinal canal stenosis (LSS). However, a strategy to prevent revision surgery has not been described.PURPOSEThe aim of this study was to review clinical and imaging findings in LSS patients with DISH extending to the lumbar segment and to propose countermeasures for prevention of revision surgery.STUDY DESIGNA retrospective study.PATIENTS SAMPLEA total of 613 consecutive patients with LSS underwent posterior decompression without fusion at our hospital and had a minimum follow-up period of 2 years. We defined patients with DISH bridging to the lumbar segment as L-DISH cases (group D, n=111), and those without as non-L-DISH cases (group N, n=502).OUTCOME MEASUREDemographic data including the rate of revision surgery, neurological examination using Japanese Orthopaedic Association score, radiological studies comprised plain lumbar radiography, CT, and high-resolution MRI were assessed.METHODSClinical features and imaging findings were compared in patients with and without L-DISH. Revision surgery and surgical procedures (conventional laminotomy or lumbar spinous process-splitting [split] laminotomy) were examined in the two groups. No funding was received for this study.RESULTSL-DISH from L2 to L4 was a risk factor for disc degeneration such as a vacuum phenomenon and for further surgical treatment. The rate of revision surgery was higher in group D than in group N (9.0% vs. 4.0%, p=.026). There was no significant difference in this rate for patients in groups D and N who underwent conventional laminotomy; however, for those who underwent split laminotomy, the rate was significantly higher in group D (16.7% vs. 2.1%, p=.0006). Furthermore, the rate of revision surgery after split laminotomy at a lower segment adjacent to L-DISH was significantly higher than that after conventional laminotomy (37.5% vs. 7.7%, p=.037).CONCLUSIONSA negative impact of lumbar spinous process-splitting laminotomy was found, especially with decompression at a lower segment adjacent to L-DISH. In such cases, surgery sparing the osteoligamentous structures at midline, including the spinous process and supra- and interspinous ligaments, should be selected.     

Complications associated with military spine injuries

Background contextTo assess the presence of complications associated with spine injuries in the Global War on Terror.PurposeTo characterize the effect of complications in and around the battlefield during Operation Enduring Freedom and Operation Iraqi Freedom from 2001 to 2009.Study design/settingRetrospective study.Patient sampleAmerican servicemembers sustaining spine injury during combat.MethodsExtracted medical records of warriors identified by the Joint Theater Trauma Registry from October 2001 to December 2009. Complications were defined as unplanned medical events that required further intervention. Complications were classified as major or minor and further subdivided among groups, including surgical and nonsurgical management, mounted (in an armored vehicle) or dismounted at the time of injury, and blunt or penetrating trauma.ResultsMajor complications were encountered in 55 servicemembers (9%), and 38 (6%) sustained minor complications. Forty-four percent (n=24) of those with major complications had more than one complication. Eleven servicemembers sustained three or more complications. There were five intraoperative complications, and 50 occurred in the perioperative period. Intraoperative complications included gastrointestinal injury, dural tear, and instrument malposition. Among patients who sustained complications, precipitating spinal injuries occurred primarily in combat (n=43 [78%]) and resulted from blunt (18) or penetrating (25) mechanisms. Complications occurred in 10 (3%) of those treated nonoperatively and 45 (25%) of those receiving surgery. Complications were higher in the dismounted group (80%) as compared with those who were mounted in vehicles at the time of injury (20%). Thirty-five percent (n=24) of surgically treated, dismounted, and penetrating injured servicemembers had complications. Seventeen percent (n=8) of surgically treated and blunt injured mounted servicemembers and 20% (n=13) of dismounted servicemembers had complications. Among the dismounted and nonspinal cord–injured servicemembers, both blunt (p=.002) and penetrating injured (p<.0005) treated with surgery were correlated with complications. Only the dismounted servicemembers with spinal cord injuries because of a penetrating mechanism were also at an increased risk for complications (p<.0005).ConclusionsPatients treated with surgery appear to be at increased complication risk regardless of the mechanism of injury. Uparmored vehicles may safeguard servicemembers from spine injuries and complications associated with their treatment. This may be reflective of the fact that less severe spinal and concomitant injuries are sustained in the precipitating trauma because of the protection afforded by the vehicle. Dismounted soldiers had more complications in all groups regardless of type of management or injury mechanism.     

Occult infection in pseudarthrosis revision after spinal fusion

Background ContextPseudarthrosis after attempted spinal fusion is yet not sufficiently understood and presents a surgical challenge. Occult infections are sometimes observed in patients with pseudarthrosis and no inflammatory signs of infection. The prevalence of such occult infection and its association with patient demographics and inflammatory markers are largely unknown.PurposeTo determine the prevalence of unexpected low-grade infection in spinal pseudarthrosis revision surgery, and to evaluate whether such infection is associated with patient demographics and inflammatory markers.Study DesignRetrospective observational study.Patient SampleOne-hundred-and-twenty-eight patients who underwent thoracolumbar revision surgery due to presumed aseptic pseudarthrosis after spinal instrumentation.Outcome MeasuresCulture-positive infections or noninfectious pseudarthrosis.MethodsSamples were routinely taken for microbiological examination from all adults (n=152) who underwent revision surgery for presumed aseptic thoracolumbar pseudarthrosis between 2014 and 2019. A full intraoperative microbiological workup (at least three intraoperative tissue samples) was done for 128 (84%) patients, and these patients were included in further analyses. Patient characteristics, medical history, inflammatory markers, and perioperative data were compared between those with and without microbiologically-confirmed infection based on samples obtained during pseudarthrosis revision.ResultsThe microbiological workup confirmed infection in 13 of 128 cases (10.2%). The predominant pathogen was Cutibacterium acnes (46.2%), followed by coagulase-negative staphylococci (38.5%). The presence of infection was associated with the body mass index (30.9±4.7 kg/m² [infected] vs. 28.2±5.6 kg/m² [controls], p=.049), surgery in the thoracolumbar region (46% vs. 18%, p=.019), and a slightly higher serum C-reactive protein level on admission (9.4±8.0 mg/L vs. 5.7±7.1 mg/L, p=.031). Occult infection was not associated with age, sex, prior lumbar surgeries, number of fused lumbar levels, American Society of Anesthesiologist score, Charlson Comorbidity Index, presence of diabetes mellitus, and smoking status.ConclusionsOccult infections were found in 10% of patients undergoing pseudarthrosis revision after spinal fusion, even without preoperative clinical suspicion. Occult infection was associated with higher body mass index, fusions including the thoracolumbar junction, and slightly higher C-reactive protein levels. Intraoperative microbiological samples should be routinely obtained to exclude or identify occult infection in all revision surgeries for symptomatic pseudarthrosis of the spine, as this information can be used to guide postoperative antibiotic treatment.     

Causes and Costs of a Decade of Litigation Following Emergency Appendectomy in England

Background

There has been recent interest in the delayed and nonoperative management of appendicitis. The present study assessed the causes and costs of litigation against surgeons following emergency appendectomy, with an emphasis on claims relating to preoperative management.

Materials and methods

Data were obtained from the English NHS Litigation Authority for claims relevant to appendectomy between 2002 and 2011. Two authors independently extracted data and classified it against predetermined criteria.

Results

Successful litigation occurred in 66 % of closed cases (147/223) with a total payout of £8.1 million. There were 24 claims against organizational operating room delays (9 % of total) and 27 against delayed diagnosis (10 %), with respective success rates of 70 and 68 %. From 21 claims relating to damage to fertility, nine were due to either delayed diagnosis or organizational operating room delays. Misdiagnosis was the second most common cause for litigation (16 %), but it had the lowest likelihood of success (49 %). Faulty surgical technique was the most common reason for litigation (39 %), with a 70 % likelihood of success. Of eight claims related to fatality, one was due to unacceptable preoperative delay leading to preventable perforated appendicitis. The overall highest median payouts were for claims of damage to fertility (£52,384), operating list delays (£44,716), and delayed diagnosis (£42,292).

Conclusions

There were significant medicolegal risks surrounding delays related to access to operating lists and diagnosis. Whereas future evidence regarding the safety of delayed appendectomy may provide scientific defense against these claims, the present study provides evidence of the current medicolegal risk to surgeons following delayed treatment of appendicitis.     

The impact of system and diagnostic errors for medical litigation outcomes in orthopedic surgery

BackgroundMedical litigation resulting from medical errors has a negative impact on health economics for both patients and medical practitioners. In medical litigation involving orthopedic surgeons, we aimed to identify factors contributing to plaintiff victory (orthopedic surgeon loss) through a comprehensive assessment.MethodsThis retrospective study included 166 litigation claims against orthopedic surgeons using a litigation database in Japan. We evaluated the sex and age of the patient (plaintiff), initial diagnosis, diagnostic error, system error, the time and place of each claim that led to malpractice litigation, the institution's size, and clinical outcomes. The main outcome was the litigation outcome (acceptance or rejection) in the final judgment. Acceptance meant that the orthopedic surgeon lost the malpractice lawsuit. We conducted multivariable logistic regression analyses to examine the association of factors with an accepted claim.ResultsThe median age of the patients was 42 years, and 65.7% were male. The litigation outcome of 85 (51.2%) claims was acceptance. The adjusted median indemnity paid was $151,818. The multivariable analysis showed that diagnostic error, system error, sequelae, inadequate medical procedure, and follow-up observation were significantly associated with the orthopedic surgeon losing the lawsuit. In particular, claims involving diagnostic errors were more likely to be acceptance claims, in which the orthopedic surgeon lost (adjusted odds ratio 16.7, 95% confidence intervals: 4.7 to 58.0, p < 0.001). All of the claims in which the orthopedic surgeon lost were associated with a diagnostic or system error, with the most common one being system error.ConclusionsSystem errors and diagnostic errors were significantly associated with acceptance claims (orthopedic surgeon losses). Since these are modifiable factors, it is necessary to take measures not only for individual physicians but also for the overall medical management system to enhance patient safety and reduce the litigation risk of orthopedic surgeons.