In the final case study 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 causing them much distress. The series presented three different outcomes following surgery for nerve compression syndrome. In each case Dr Ramos-Galvez reviewed the clinical evolution of the patient’s condition, opined on causation and discussed the medico legal implications.
CASE THREE: MINOR SURGERY RESULTING IN OPIOID ADDICTION
Presentation and Clinical evolution:
Mr M was a plumber in his mid-fifties. He had suffered several episodes of sciatica throughout his life and then developed a persistent episode that rendered him unable to work. After deriving only mild improvement from nerve root injections, he eventually underwent a microdiscectomy which is a minimally invasive surgical procedure performed on patients with a herniated lumbar disc. The procedure was uneventful and Mr M was discharged after 24 hours with his sciatica cured.
Ten days later, Mr M started to complain of severe lower back pain, which was within the operated level. His GP prescribed analgesic medication which did not help. Mr M was offered morphine, since his levels of pain were such that he was threatening to commit suicide. The morphine did not help. Attendance at A&E resulted in admission with suspected discitis, which isinflammation that develops between the intervertebral discs of the spine, an MRI confirmed the diagnosis. Blood tests showed very elevated inflammatory markers. Open biopsy and surgical washout were carried out, confirming infection, and antibiotics were started.
Improvement was slow. The pain was very severe and required increasing doses of opioids, in combination with other analgesics and nerve painkillers. The infection required 9 months of oral antibiotics. Clinically, the pain had a profound effect on Mr M’s life both on a personal and professional level. He was made redundant and his mood deteriorated. He became despondent, his social structure disappeared as he became more withdrawn. A surgical consultation suggested an injection might help, once blood results had returned to normal. Mr M pinned his hopes on this treatment. A year after the surgery, microbiology confirmed that the infection had resolved biochemically. The injection was carried out but unfortunately it did not alleviate his pain. Mr M continued to increase his opioid medication and developed signs of hypogonadism resulting in loss of libido, impotence and gynaecomastia – these proved to be the final events that tipped his psychological balance.
Mr M failed to attend several clinic appointments and was discharged. Two years later, Mr M arrived in my clinic with a new referral from his GP. He had recently returned from Thailand after abandoning his family. He had isolated himself in Thailand, smoking opium and drinking heavily, until the money ran out. He was put on an opioid reduction programme, including use of opioid sparing drugs combined with a psychological programme. This has helped him to understand and come to terms with what had happened – he is still in treatment.
What went wrong?
Infection is a recognised complication of surgery. When infection happens, it is the consequence of bacteria that live in the skin of the patient surviving the cleaning process, penetrating the wound and multiplying in a thriving environment. Spinal discs have minimal blood supply which renders them prone to infection and difficult to treat. Infection most often occurs around two weeks after surgery causing discitis. The main symptom is severe pain.
In this case infective discitis is present and Mr M’s response to the diagnosis demonstrated significant maladaptive behavior. He did not undergo psychological screening which would have assisted and intervention in the form of a multi-disciplinary team assessment might have prevented his deterioration.
The levels of opioids he needed and was taking within a short timeframe were a bad prognostic sign. His lack of response to any other pharmacological agent was also worrying as was his self-imposed isolation. All these factors represent maladaptation to adversity and a multi-disciplinary assessment and psychological screening might have helped prevent this outcome.
From a medicolegal perspective:
Infection is a recognised complication of surgery and its occurrence does not always represent a breach of duty. Diagnosis and management were appropriate in this case.
Better assessment and cooperation between primary and secondary care providers may well have exposed previous psychiatric events and highlighted Mr M’s exposure to adverse events in childhood that may have pre-empted his abnormal response to adversity and inability to cope.
The analgesic management of Mr M’s condition was appropriate, with the exception of increasing doses of opioids. Escalation of opioids was often left to patient decision and his GP should have restricted supply and monitored him carefully and this may have helped prevent the development of a significant opioid problem, not only from the perspective of addiction to fast titration opioids, but also in respect of the patient’s continuous use of the drugs despite the lack of efficacy and systemic effects. This may well represent a breach of duty through failure to establish an appropriate contract between prescriber and patient that clearly establishes the appropriateness of the prescription and use of opioids.
Sadly this is not an isolated case study when it comes to understanding the complex management and treatment of pain which often requires a multi-disciplinary approach led by a Consultant in Pain Medicine. A pain expert has the skill and experience to analyse the history of a patient to identify causation in a medico legal claim and and identify any “red flags” which have been missed by treating physicians. Dr Ramos-Galvez has extensive experience in treating a wide range of pain conditions and is increasingly sought for his opinion in complex medico legal cases involving pain for both defendant and claimant. He can be instructed via Medicolegal Associates on 0207 118 0650.