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UNSPLASH
A surgeon was found to have violated the patients’ rights code by failing to treat a woman whose spinal screws were “misplaced.”
A woman in her 60s was left paralyzed after the screws were “misplaced” during spinal surgery, requiring multiple operations in what was described as a “tragic surgical outcome.”
A report, released Monday by Deputy Commissioner for Health and Disability Rose Wall, found that an unidentified orthopedic surgeon violated the patients’ rights code for failing to treat the woman, known as Ms. A.
In May 2017, Ms A underwent spinal fusion surgery, a procedure to permanently connect two or more vertebrae to eliminate movement, using techniques to mimic the normal healing process for broken bones. Metal plates, screws, or rods can be used to join the vertebrae together, so that they heal as one.
But during the six-hour surgery there were problems with the navigation system used to help place the screws, so the surgeon, identified only as Dr. D, used both the computerized system and hands-free techniques to insert the screws. .
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After the surgery, Ms. A began to experience chest pain.
The scans showed that the T9 screw (the screw in the ninth thoracic vertebra) may have been slightly out of place.
However, Dr. D did not feel that this was necessarily responsible for Ms. A’s chest pain, according to the report.
When she was discharged, the surgeon’s letter to Ms A’s GP noted the pain in her chest and stated that, through X-rays, “in general, I think the hardware from T9 to the pelvis is in place satisfactorily.
SUPPLIED / Stuff
The woman, in her 60s, underwent spinal fusion surgery. A subsequent scan showed that the screws were misplaced.
“Although I notice that the right side T9 screw is a bit outboard … this shouldn’t be in danger …” the letter continued.
The following month, Ms A was admitted to hospital after suffering a fall.
A CT scan showed that the screws had been lost, requiring surgery to review the placement.
His pain persisted and an MRI showed a disc bulge (bulging of a part of the disc wall in the spine), requiring a third operation.
This operation involved removing the T9 / T10 screws and decompression to relieve pressure on the spinal cord or nerves.
However, Ms A experienced a worsening of her paraplegia (lower body paralysis) and a second CT scan identified “significant” dissociation in her spine.
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Ms. A required three more operations after the initial spinal fusion surgery.
Ms. A underwent a fourth operation in July 2017 and had to be transferred to the column unit.
He now suffers from paralysis of the lower body and ischemia of the spinal cord, where the blood supply to the spine is cut off.
In the report, her daughter said: “In May 2017, [Mrs A’s] life changed forever at the hands of a qualified surgeon. “
He is now “totally dependent on all the cares of life, described by the spinal unit consultant as a” tragic surgical outcome. “
Wall was critical because Dr. D lost the screws during the first surgery.
“As a result of the misplaced screws in the first operation, Ms. A had to undergo further surgeries and treatments, and suffered ongoing pain and loss of mobility.”
Wall recommended that the surgeon apologize to Ms. A and her family.
Wall recommended to Dr. D that he inform HDC about the changes he plans to undertake and how this changed or improved his practice, and recommended that the Medical Council consider whether his competence should be reviewed.
