In the second in a series of three case reviews, Dr Ivan Ramos-Galvez LMS, FRCA, FFPMRCA, Expert Witness and Consultant in Pain Medicine with a sub-specialty in spinal surgery, discusses how complications can develop into chronic pain after spinal surgery for some patients much to the distress of the patient. This series presents three different outcomes of surgery for nerve compression syndrome. In each case Dr Ramos-Galvez reviews the clinical evolution of the patient’s condition, opines on causation and discusses the medico legal implications.
CASE STUDY TWO: AN UNEXPECTED COMPLICATION
Presentation and clinical evolution:
Mrs A, a young woman in her mid-twenties led an active life and worked in a nursery. She had been complaining of a combination of severe low back pain and unilateral sciatica for five years. She underwent the usual regimen of physiotherapy and analgesics, with very little improvement. Mrs A was sent for an MRI scan of her lumbar spine, which identified a segment of wear and tear in the low lumbar area with narrowing around some nerves. She was referred to a spinal surgeon and given a temporary nerve block to help with her leg pain. Mrs A had surgery which improved the pain initially and her sciatica no longer caused her a problem.
However, Mrs A was not well enough to be able to return to work – she struggled to sleep at night because her foot felt very sore and sensitive and she could not wear shoes. Her foot was stiff, and she needed to wrap it in layers of socks to keep it warm. Her leg eventually gave way and her GP referred her to a foot trauma surgeon. Her scans were normal and, in the absence of any explanation for her symptoms, Mrs A was discharged from the foot clinic with a diagnosis of “pain syndrome”.
Mrs A’s symptoms continued to deteriorate culminating in her leg changing in colour below the knee. During a routine post-operative visit, the spinal surgeon enquired about her limping and diagnosed suspected “chronic pain syndrome” and the patient was referred to me.
Following a consultation, I confirmed the diagnosis of Complex Regional Pain Syndrome (CRPS) and referred Mrs A to physiotherapy and prescribed analgesic medication. A sympathectomy (the surgical cutting of a sympathetic nerve) allowed Mrs A to stop limping, walk without crutches, wear shoes and return to work.
Sadly, seven months later the symptoms returned. A repeat procedure with a pulsed radiofrequency offered similar results and has allowed Mrs A to resume a normal life. She is not pain free, but the pain is uncomfortable rather than intrusive.
What went wrong?
Neuropathic pain is a recognised complication of any surgical procedure. During spinal canal surgery there is active manipulation of the nerve roots. This sometimes causes abnormal reactions in the way that nerves process information and respond to it. CRPS is an abnormal expression of nerve activity where different modalities of nerve signalling get mixed and the effect is a mixture of changes in blood flow together with nerve pain and stiffness and swelling.
Predicting who will react to surgery in this way is impossible. There is no predictive screening tool that can provide this information. Mrs A’s foot symptoms could have been dealt with much sooner had the GP considered the symptoms she was experiencing instead of focusing on anatomical causes for the symptoms she complained of in her foot that, by all accounts, was healthy. Whilst the foot surgeon for his part, identified a “pain syndrome” he failed to initiate prompt and appropriate treatment with physiotherapy and referral to a pain specialist.
Complications such as those experienced by Mrs A are recognised events that can occur after surgery and do not necessarily represent a breach of duty. Direct trauma to a nerve can be caused by inappropriate surgical technique causing excessive tissue trauma. This may represent a breach of duty and its only through the careful and analytical review of the medical notes and history by an experienced expert that it is possible to identify the incidental versus accidental occurrence ofneuropathic symptoms.