A 73-year-old patient had a history of previous L3-L4 anterior interbody fusion in 2005, and oblique lateral interbody fusion of L2-3 with posterior fusion in 2006. She eventually began to suffer from recurrent back, buttock, and bilateral leg pain and neurogenic claudication symptoms. Her imaging showed degenerative disc disease at L4-L5 with severe central stenosis and severely gapped facet joints, as well as L1-L2 degenerative disc disease with segmental kyphosis and severe sagittal plane imbalance. She failed conservative treatment.
On 12/7/2021, the patient underwent the following anterior and posterior spine surgeries:
Anterior:
1. Anterior retroperitoneal exposure of L1-2, L4-5 and L5-S1 placement of retractors and closure
2. Anterior lumbar diskectomy L1-2, L4-5, and L5-S1
3. Anterior lumbar interbody fusion with RJ-BMP-2, autograft, allograft and mesenchymal cell complex at L1-2, L4-5 and L5-S1
4. Implantation of Medtronic titanium coated peak interbody cage fixation, L1-2, L4-5 and L5-S1
5. Divergence 4-hole plate and screw fixation L5-S1
6. SSEP, MEP neuro monitoring
Posterior:
7. L4-5 posterior column osteotomy, bilateral facetectomy with central decompression and bilateral foraminotomies
8. T10-S1 revision posterior and posterior lateral intertransverse process fusion with RH-BMP-2, autograft, allograft and mesenchymal stem cell complex
9. T10-S1 instrumentation and segmental cortical pedicle screw and rod fixation utilizing Mazor robotic guidance and o-arm
10. Instrumentation with bilateral S1 ala-iliac screw fixation
11. T11-12, T12-L1 bilateral facetectomies
12. L2-3 removal of posterior hardware
13. Left iliac crest mesenchymal cell harvest (separate incision)
14. T10-T11 translaminar epidural injection for pain control
15. L1-2 blood patch
16. Field block of surgical incision
17. SSEP, MEP monitoring, and direct pedicle screw stimulation technique
***The anterior retroperitoneal exposure, retractor placement, and closure were performed by a general surgeon, while the spine surgeries themselves were performed by an orthopedic spine surgeon.***
The surgeries themselves seemed to go OK, although the patient was hypotensive in the PACU and required pressors and transfusions. The patient was discharged to inpatient rehab 9 days after the surgery, on 12/16/2021.
On 12/27/21, she was readmitted with complaints of chest and abdominal pain, chills, and an increasing white blood cell count. Her abdomen was hard and distended. Imaging showed loculated complex abdominal ascites. She was eventually found to have a complete transection of her left ureter, urinoma, and left hydronephrosis. The patient underwent paracentesis and placement of a retroperitoneal drain and percutaneous nephrostomy tube.
The patient eventually underwent a left nephrectomy, as it was felt to be a better option for her than ileal ureteral replacement or auto-transplantation.
My main questions are:
1. Is this kind of ureteral transection considered a known complication that can occur without negligence?
2. If so, did the delay in diagnosing it likely make any difference in terms of her options for repair, reconstruction, or nephrectomy?
3. If the transection was due to negligence, is there any way to determine whether it was more likely the fault of the general surgeon or the orthopedic spine surgeon?
If you have borne with me and read this far, thanks for your time.
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No questions yet!
Do you believe there might have been medical error?
The standard of care is to identify the anatomy and protect it
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This should have been easily seen prior to discharge
What makes you a good expert for this case?
I’m a board certified Otho spine surgeon
How often do you encounter cases similar to this one in your practice?
Not often seen but has happened
Do you believe there might have been medical error?
This is a known possible complication of a complex exposure and orthopedic procedure. The exposure and the instrumentation do put these structures at risk and this is routinely discussed with patients preoperatively. While it is possible that there was medical negligence or error that caused this injury, it appears equally possible that the injury could have happened without any specific negligence.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is difficult if not impossible to say in this case with the information before us. If we knee the exact location of the ureteral injury, that might go a long way toward determining the stage at which it was harmed, and then also whether there was causation. The further anterior, meaning further away from the spine, that the injury was, the less likely that it occurred as part of the orthopedic procedure. If it occurred during exposure, it is also possible that the patients pre existing scar tissue from prior surgeries and health problems may have led to the injury by making dissection especially difficult.
What makes you a good expert for this case?
I have reviewed several cases similar in some respects to this one, and have personally scrubbed many of these cases. I also have been present for the abdominal exposure portion of these procedures, which many orthopedic surgeons have not, so I have some perspective on that as well.
How often do you encounter cases similar to this one in your practice?
Infrequently regarding complications of anterior and posterior spine surgery, approximately once per annum
Do you believe there might have been medical error?
Ureteral transaction, especially in a revision setting, is a known complication. It can be difficult to diagnose initially, however, a delay in diagnosis typically does not have long-term sequela. The treatment remains the same, which is nephrectomy.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is a known complication, and not a medical error.
What makes you a good expert for this case?
I am a board-certified, fellowship trained orthopedic spine surgeon in my 19th year of active practice. I have extensive clinical, forensic, and medical expert testimony experience. I have previously reviewed at least two other cases of this complication.
How often do you encounter cases similar to this one in your practice?
It is now my preference to do all my lumbar surgeries from a poster approach in order to avoid complications, such as this, and others, such as abdominal and vascular injuries. However, it is within the standard of care to elect for a retroperitoneal approach. While I do not encounter this complication in my clinical practice, I have reviewed several cases of this as an expert.
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