Misplacement Of Screws In Spinal Surgery

Deputy Health and Disability Commissioner Rose Wall today released a report finding an orthopaedic surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the treatment of a woman requiring spinal surgery.

The woman, aged in her sixties at the time, underwent spinal fusion surgery performed by an orthopaedic surgeon at a private hospital. There were issues with the computer navigation system, and the orthopaedic surgeon used a combination of the navigation method and standard anatomical points to insert screws into the woman’s spine.

The following month, the woman was admitted to the public hospital having suffered a fall. A CT scan identified that the screws inserted during the spinal fusion had been misplaced. The orthopaedic surgeon performed surgery to correct this.

Subsequently, the woman experienced ongoing pain, and an MRI scan showed disc protrusion (bulging of a portion of the disc wall in the spine). The woman underwent further spinal surgery, but experienced worsening paraplegia (lower body paralysis). A CT scan identified a dissociation in the spinal column. As a result, the orthopaedic surgeon and a colleague undertook further spinal surgery. Subsequently, the woman was transferred to a Spinal Unit. She requires ongoing care for paraplegia.

Deputy Commissioner Rose Wall was critical that the orthopaedic surgeon misplaced the screws during the first surgery, and that decompression was performed without further protection during the third surgery. She was also critical of the district health board (DHB) in relation to the delay in seeking input from the Acute Pain Service team.

"As a result of the misplaced screws in the first operation, [the woman] had to undergo further surgeries and treatment, and suffered ongoing pain and loss of mobility," said Ms Wall. "Accordingly, I find that [the orthopaedic surgeon] did not provide services to [the woman] with reasonable care and skill."

Ms Wall recommended that the orthopaedic surgeon report back to HDC regarding the changes he plans to undertake and how this has changed and/or improved his practice, and apologise to the woman and her family. She also recommended that the Medical Council of New Zealand consider whether a review of the orthopaedic surgeon’s competence is warranted.

Ms Wall recommended that the DHB report back to HDC on its plan to ensure that registrars and house officers are aware that it is the responsibility of medical staff to contact the Acute Pain Service for a review of a patient’s pain.

The full report for case 18HDC01671 is available on the HDC website.

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