Analysis of reasons for medical malpractice litigation due to laminectomy (2024)

Keywords: laminectomy; litigation; malpractice; Westlaw Edge; VerdictSearch

Malpractice claims analysis is performed by several medical specialties to provide insight into patient values, methods to improve quality of care, and risk factors for litigation pertaining to specific procedures or treatments.^1–8 Among all medical and surgical specialties, neurosurgery is the most litigious specialty, closely followed by orthopedic surgery, which ranks fourth among medical malpractice claims.⁹ Concurrently, over 19% of neurosurgeons and 15% of orthopedic surgeons receive a malpractice claim each year, with many of these claims attributed to spinal procedures.^9,10

Laminectomy is a commonly performed spinal procedure with over 4.5 million operations recorded in the United States from 2001 to 2011.^11,12 Laminectomy may be performed as a stand-alone operation or concurrent with another procedure such as a discectomy, foraminotomy, or spinal fusion. Analysis of malpractice cases due to laminectomy may provide clinicians with a better understanding of malpractice risk factors and, in turn, practices through which these risk factors may be mitigated. As such, the aim of our study was to identify the incidence and characteristics of malpractice lawsuits pertaining to laminectomy performed either as a stand-alone operation or concurrent with another procedure by querying Westlaw Edge and VerdictSearch, two well-established legal databases that are widely used in medicolegal research.^3,13–15

Methods

Results

Of the 4732 total cases reviewed, 201 involved a basis of litigation due to laminectomy, with the remaining cases excluded from the final analysis owing to topic irrelevance (Fig. 1). The included 201 cases were classified into 6 categories (Table 1), the descriptions of which are detailed in Table 2. The geographical distribution of the litigations is included in Table 3.

The most commonly cited reason for litigation was delay in surgical intervention (n = 106). In total, 40.6% (n = 43) of cases in this category ruled in favor of the defendant, while 17.0% (n = 18) and 9.4% (n = 10) resulted in a plaintiff or mixed verdict, respectively. The remainder of cases resulted in an out-of-court settlement (7 [6.6%]) or did not provide a recorded verdict (28 [26.4%]). To further delineate between common factors that contributed to delay in treatment, the following subcategories were created: delay in diagnosis (n = 60), treatment with conservative therapy (n = 27), delayed referral (n = 8), and other (n = 11). Among these subcategories, delay in diagnosis imparted comparatively more unfavorable outcomes to providers, with 20% (n = 12) of cases ruling in favor of the plaintiff and verdicts yielding an average payment of $4,727,639.

The second most prevalent category of litigation pertained to perioperative complications, with 38 instances of litigation identified. Among these cases, dural tear (n = 8), complete or incomplete spinal cord injury (n = 7), nerve root damage (n = 6), surgical site infection (n = 6), epidural hematoma (n = 4), worsening symptoms (n = 4), cauda equina syndrome (n = 2), and hemorrhage (n = 1) were listed as complications that led to litigation. Cases in this category yielded a defendant ruling in 39.5% (n = 15) of cases and a plaintiff or mixed ruling in 15.7% (n = 6) and 7.9% (n = 3) of cases, respectively. The remainder of cases (n = 11) resulted in an out-of-court settlement or were unavailable for review (n = 3). Complete or incomplete spinal cord injuries more commonly produced unfavorable rulings with 42.8% (n = 3) and 28.6% (n = 2) of cases in this subcategory resulting in a plaintiff verdict or settlement, respectively, and yielded an average payment of $2,037,250.

Inadequate or delayed treatment of postlaminectomy syndrome was the third most common reason for litigation, accounting for 26 of the cases identified by our query. Despite its prevalence, cases in this category imparted comparatively little risk to providers, with only 3.8% (n = 1) of cases ruling in favor of the plaintiff, 15.4% (n = 4) yielding a mixed verdict, and none resulting in an out-of-court settlement.

Instances of an incorrect choice of procedure (n = 14), inadequate follow-up care (n = 10), and inadequate informed consent (n = 7) comprised the remainder of our identified instances of litigation. Litigations concerning a perceived incorrect choice of procedure yielded a defendant ruling in 78.6% (n = 11) of cases, whereas those involving inadequate follow-up care or inadequate informed consent produced this result in 50.0% (n = 5) and 71.4% (n = 5) of cases, respectively.

Across the 201 recorded instances of litigation due to laminectomy, 47.3% (n = 95) ruled in favor of the defendant, 9.0% (n = 18) resulted in a mixed ruling, 15.9% (n = 32) ruled in favor of the plaintiff, 9.5% (n = 19) were resolved with an out-of-court settlement, and 18.4% (n = 37) did not feature a recorded verdict (Fig. 1). An average payment of $4,530,277 resulted from cases that ruled in favor of the plaintiff, whereas out-of-court settlements yielded an average payment of $1,193,146. Among the malpractice claims that disclosed the specific spinal region (n = 166), 42 (25.3%), 30 (18.1%), and 94 (56.6%) cases involved the cervical, thoracic, and lumbar spine, respectively (Fig. 2). With respect to the number of cases that produced a nondefendant ruling per spine region, 21 (50.0%), 16 (53.3%), and 28 (29.8%) cases involving the cervical, thoracic, and lumbar regions, respectively, ruled against the defendant. The mean ± SD plaintiff ruling or settlement payment amounts for cases involving the cervical, thoracic, and lumbar regions were $3,070,910.20 ± $3,789,884.82, $1,561,222.25 ± $1,157,672.55, and $1,900,000.00 ± $2,243,653.85, although no significant difference was observed between these values (p = 0.528). Cases involving laminectomy performed at the lumbar level were significantly more likely to result in a defendant rather than plaintiff verdict when compared with laminectomies performed at the cervical (p < 0.001) or thoracic (p = 0.007) level.

Discussion

Malpractice analysis provides a novel perspective into patient values, the relative risk of litigation for a certain procedure or practice, and the contributing factors that lead to the development of a malpractice claim. Court proceedings impart severe financial and emotional tolls on both plaintiff and defendant parties, promoting defensive medical practices and contributing to the high rates of physician burnout seen in spine surgery.^22,23 Additionally, malpractice litigation has been found to increase the cost of physician and hospital services by as much as $97.5 billion annually, thus exacting a significant financial toll on the healthcare system.²⁴ As such, discovering ways to mitigate the incidence of legal disputes and malpractice claims is important to decrease the emotional, psychological, and financial burdens on both patients and physicians.

This study suggests that there are several well-documented risk factors for malpractice claims attributed to laminectomy. Delay in surgical treatment was identified as the most common reason for litigation pertaining to laminectomy. Delayed radiological or clinical diagnosis of spinal cord pathologies was the most frequently cited reason for delay in surgical treatment. A delay in diagnosis of acute pathology accounted for 51.7% (n = 31) of cases involving delayed diagnosis, with the remaining 48.3% (n = 29) of cases due to delay in diagnosis of chronic pathology (Table 4). Delayed identification of chronic conditions may be explained by the considerable amount of variation in the radiological parameters used for clinical diagnosis of stenosis requiring surgical intervention, whereas failing to diagnose an acute pathology may be a product of comparatively poor diagnostic sensitivity and lack of clinical suspicion.^25–27 The use of conservative therapy despite the presence of pathology indicating surgery was also a commonly cited reason for litigation due to delayed treatment. In a review of surgical intervention compared with nonoperative treatment, Zaina et al. reported inconclusive evidence for the benefit of nonoperative treatment for stenosis in comparison with surgical intervention.²⁸ Concurrently, Zweig et al. found that increasing duration of nonoperative treatment was not associated with objectively improved outcomes after lumbar laminectomy.²⁹ These studies, in light of our findings, suggest that opting for the use of prolonged conservative therapy in the setting of significant pathology or impairment may be clinically inappropriate and may expose clinicians to increased risk of litigation. Altogether, our findings involving delayed treatment suggest that the early-treatment stages for spinal pathologies are highly susceptible to litigation.

Malpractice claims due perioperative complications were another frequently cited reason for litigation due to laminectomy. For some patients or families, any deviation from the expected or desired outcome may imply malpractice. In contrast, it is established within the medical community that a maloccurrence does not necessarily equate to deviation from standard of care or malfeasance. However, if a surgeon does not fulfill the responsibility of informing the patients of the expected, as well as realistic, courses of surgical and medical treatment, then the patient is at risk of feeling misinformed or deceived. These findings point to an underlying disconnect in understanding and the high prevalence of inadequate communication between the surgeon and patient regarding the realistic expectations and implications of surgery. These findings suggest that clear and thorough communication may considerably mitigate the incidence of malpractice claims. Given these findings, limiting iatrogenic risks to the best of the surgeon’s capability while emphasizing communication with the patient regarding potential perioperative risks and realistic postoperative outcomes may be best practices to mitigate litigation.

When viewed together, the relative incidence rates of these categories present an interesting finding regarding the litigation risk for laminectomy, as delayed or denied treatment (n = 106) far outnumbered the cases of perioperative complications (n = 38). While surgeons may assume that the highly invasive nature of surgery imparts the greatest risk for litigation, our study suggests that the stages of treatment prior to surgical intervention may actually account for the majority of the risk for legal action. Notably, the prolonged use of conservative therapy in the setting of significant pathology or impairment, despite being thought of as a comparatively safe method of treatment, may impart significant risk of litigation. Although this finding may imply risk to providers who elect to prolong conservative therapy, it should be strongly qualified that the incidence of malpractice claims should by no means replace evidence-based and patient-centered clinical decision-making. Rather, this finding should be used to bring attention to the fact that timing surgical intervention constitutes a sensitive balance and demands that the surgeons be thorough and skillful in delineating the indications for operative versus nonoperative treatment. Taken together, these categories of litigation refute the notion that risk of litigation largely stems from surgical intervention, but rather that the initial stages of treatment may be of greater importance when it comes to minimizing potential sources of malpractice.

Inadequate follow-up care, including lack of referral to physical therapy, inadequate pain control or postoperative monitoring, and premature discharge, was another identified source of malpractice claims pertaining to laminectomy. In relation to this category, inadequate or delayed long-term management of postlaminectomy syndrome was also frequently specified as a reason for litigation. Although a rare pathology, postlaminectomy syndrome (or failed back surgery syndrome) was a common basis of litigation due to the plaintiff’s chronic persistence of radiculopathy and subjective pain outside of the perioperative period after surgical intervention. Most notably, within this subset of litigation, the provider in question was often not the surgeon that performed the patient’s initial surgery but rather the physician who oversaw long-term care and pain management. This finding is consistent with the findings of a previous study that found primary care physicians to be the second most common recipients of litigation claims related to spinal surgical procedures.³ As such, the prominent incidence of litigation pertaining to this complication highlights the importance of diligent follow-up, coordination of care, and communication with both treating providers and at-risk patients postoperatively.

Cases that involved a perceived lack of informed consent or incorrect choice of procedure arose from a number of unique clinical situations. In those that argued that adequate informed consent was not obtained prior to surgery, most disputes asserted that the given consent either did not comprehensively explain the likelihood of adverse outcomes or was acquired under inappropriate circumstances. In one instance of inadequate informed consent, the plaintiff—whose laminectomy led to significant postoperative disability—claimed that her consent for the procedure was inappropriately obtained while she was under sedation. During instances of a perceived error in the practitioner’s choice of procedure, plaintiffs frequently cited an overly aggressive approach to surgical treatment, which in many cases resulted in worsening symptoms or long-term complications. In one such case, the plaintiff claimed that he was persuaded by his physician to receive an extensive multilevel laminectomy of the lumbar spine, which he argued only worsened his symptoms and ultimately was unnecessary to treat his condition. These categories of malpractice claims highlight the importance of clear and thorough communication with patients throughout the perioperative period.

Our study illustrated patterns of litigation similar to those identified by previous studies. Across several reviews of spinal surgery malpractice, the lumbar spine was identified as the region most associated with litigation.^8,30 Interestingly, our study suggests that despite the comparatively high rate of litigation for lumbar spine laminectomies, this region was also more likely to yield a defendant verdict, potentially due to a lack of spinal cord involvement at this level. Overall, this finding suggests that despite the higher incidence of lumbar spine litigation, the cervical and thoracic spine may actually impart more significant risk to providers. It should be noted, however, that it is possible that more cases were identified that involved the lumbar spine simply due to the greater frequency of lumbar laminectomies performed nationally compared with cervical and thoracic laminectomies. Nonetheless, a significant difference was observed with respect to lumbar laminectomies resulting in defendant rulings more frequently than laminectomies performed in the cervical and thoracic spine.

Conclusions

This study describes risk factors for malpractice claims pertaining to laminectomy. Lack of prompt treatment or diagnosis, perioperative complications, and inadequate management of postlaminectomy syndrome were identified as the most commonly cited reasons for litigation. Lawsuits involving laminectomy performed at the lumbar level were more likely to result in a defendant verdict compared with lawsuits involving the cervical or thoracic level. Our findings suggest that prompt and accurate diagnosis, coordination of care, timely referral for surgical intervention, and understanding of the indications versus limitations of conservative therapy may help to mitigate risk of litigation associated with laminectomy.

Addendum

In light of our findings, it is important to acknowledge the personal, financial, and medical ramifications incurred by the plaintiffs of our cohort. Specifically, it is crucial to remember that many malpractice litigations, regardless of their outcome, represent a devastating medical maloccurrence that can carry significant consequences for the patient in question. In many cases within our study, plaintiffs were rendered paralyzed, subjected to unnecessary surgeries, or burdened by chronic pain due to medical negligence and mistreatment. Therefore, it is not our aim to simply aid providers in preventing malpractice lawsuits, but also to promote mutually beneficial relationships between patients and providers in which such maloccurrences can be avoided altogether. As such, rather than viewing our results as principles for avoiding litigation, physicians should utilize our findings to advocate for safer procedural techniques, more effective diagnostic modalities, and improved communication between providers and patients throughout all stages of treatment.

Disclosures

Dr. Danisa reported personal fees from Globus Medical, Stryker Spine, and SpineArt, and grants from the Musculoskeletal Transplantation Foundation outside the submitted work.

Author Contributions

Conception and design: Cheng, Razzouk, Ramos, Danisa. Acquisition of data: Cheng, Bohen, Danisa. Analysis and interpretation of data: Cheng, Bouterse, Razzouk, Ramos, Danisa. Drafting the article: Cheng, Bouterse, Razzouk, Danisa. Critically revising the article: Cheng, Bouterse, Razzouk, Ramos, Danisa. Reviewed submitted version of manuscript: Cheng, Bouterse, Razzouk, Danisa. Approved the final version of the manuscript on behalf of all authors: Cheng. Statistical analysis: Razzouk. Administrative/technical/material support: Cheng, Bohen. Study supervision: Cheng, Ramos, Danisa.