Whereas lumbar discectomy will relieve leg pain from nerve root irritation 90% of the time, it fails to cure low back pain (Medical Litigation News Volume 3, Issue 5) in 40% [1 ].
PRACTICE POINT Spinal surgery undertaken for back pain without leg symptoms can be justified only under exceptional circumstances |
The only absolute indication for emergency operation on an intervertebral disc (Medical Litigation News Volume 3, Issue 1) is the presence of attributable problems of bladder or bowel control and/or acute-onset neurological deficits, typically numbness in the saddle area and weakness.
Such cauda equina syndrome caused by an acute extrusion of a fragment of intervertebral disc must be operated on within 24-48 hours of onset of symptoms[1a] for the neurological injury to be probably reversible[1b,1c].
The surgery usually required is laminectomy[1d] and discectomy[1e].
More commonly, neurogenic bladder arises from spinal stenosis, and the amount of improvement is unpredictable and often limited[2.], [3.], [4.]
PRACTICE POINT Delay in operating in the presence of acute bladder symptoms may be actionable |
Compression of the nerve roots or spinal cord by intervertebral disc fragments requires urgent spinal surgery, whereas nerve root irritation as in sciatica may settle spontaneously.
Operating at the wrong level is indefensible. If there is any doubt on the basis of pre-operative diagnostic imaging, the level must be confirmed radiologically in the operating room.
Informed consent requires disclosure of risk of neurological damage, dural leak, postoperative infection and anesthetic complications. Benefits and risks of the different types of discectomy should be discussed.
Damage to the outer lining of the spinal cord (dura mater) occurs in 5% of cases and does not necessarily indicate substandard surgical technique.
A few patients have a postoperative leak of cerebrospinal fluid, and this usually settles spontaneously.
PRACTICE POINT Required pre-operative disclosure includes
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Postoperative infection, devastating as it may be, does not generally reflect demonstrable failure of surgical or nursing technique (Medical Litigation News Volume 2, Issue 9).
Postoperative neurological deterioration such as loss of sensation over the sacrum, particularly if accompanied by decreased anal muscle tone or bladder symptoms, is a reason to consider urgent re-operation[5,6,7].
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