Misplacement of screw during Spinal Surgery: NCDRC dismisses case against AIIMS
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Delhi: The National Consumer Dispute Redressal Commission (NCDRC) has dismissed a case of medical negligence against All India Institute Of Medical Sciences (AIIMS), Delhi and its doctors wherein the petitioner alleged that the patient became paralyzed due to misplacement of the screw during surgery for congenital spinal deformity.
As per the discharge summary, one screw penetrated the vertebral canal and caused Grade – III perforation in the spinal cord. The spinal cord was severely damaged and the patient became paralyzed for the rest of her life, with loss of bowel and urinary control.
It was also alleged that the C-arm was not used during the operation and the first surgery was conducted by an orthopedic surgeon and not a neurologist.
However, the court did not find the doctors to be negligent and stated that "In Spinal Surgery, it is apparent that any surgical procedure complications are inherent. During surgery after fixing the rod through screws along the side of the affected area, the rod is manipulated to correct the deformity and straighten the spine. It is not uncommon that while putting the rod into a corrective position, at times the screws move slightly from the original position, which can cause a neurological or vascular problem in few patients."
The petitioner submitted that the patient was suffering from congenital spinal deformity and for treatment, they consulted the Head of Congenital Kyphosis Department at All India Institute of Medical Sciences (AIIMS). The patient had been advised urgent surgery.
In the petition, it was stated that after the operation, one junior doctor came from OT and informed the complainant that the operation was successful. The patient's father went to see his daughter in the recovery room, but she was in a semi-conscious state & crying. He also noticed no movements in her legs and the same was informed by the duty doctors.
Thereafter, a CT scan of the operated area was done and it revealed that one screw was pressing the spinal cord and as a result, thereof the reoperation was necessary for removal of the said screw.
It was alleged that the C-arm was not used during the operation as it was not functioning properly and it was not disclosed by the hospital and the doctors. Moreover, during any spinal surgery, the presence of a Neurosurgeon was a must, but in the present case, the operation was performed under the supervision of an orthopedic surgeon, the counsel appearing for the petitioners contended.
After the operation on the insistence of the doctor (another petitioner in the case), then only a Neurosurgeon was called. Thereafter, the second operation was conducted and the patient remained in ICU for 10 days, but there was no recovery in movements of the lower part of the body.
The petitioner alleged that due to alleged negligence from the doctor during both the operations, the spinal cord was severely damaged and the patient became paralyzed for the rest of her life, with loss of bowel and urinary control. The paralysis of the patient did not improve even though the petitioner tried to consult other specialists.
Being aggrieved, the complainant approached the apex Commission against AIIMS and the treating doctors for gross carelessness and deficiency in service causing complete paralysis of the lower part of the patient's body and further complications and damage to kidneys, urinary bladder, etc.
The counsel for the hospital and the doctor denied the allegations and submitted that the doctors acted immediately once the accidental misplacement of the screw was detected. It was further submitted that the treating doctor was an Orthopaedic-spine surgeon with rich experience in spinal deformity correction. He had been trained in spine surgery at AIIMS institute and abroad also. He examined the patient and suggested surgery to avoid further spinal deformity which progresses with the growth of the patient.
"It usually leads to Grotesque deformity with respiratory problems and neurological deficit. The parents were clearly explained about the operative risks involved in the spinal surgery including the neurological and vascular complications. The patient's father is a doctor by profession and he was fully aware and understood the risks and complications involved in spinal surgery," the counsel for the hospital and doctors submitted.
After accepting all the discussion, the patient's father gave two informed /special consent in his own handwriting mentioning specifically the complications, stated the hospital. It was submitted that the spinal surgery was performed by the doctor and his team with the use of a C-arm. After the surgery as soon as, the displacement of the screw was identified on the CT scan, a Neurosurgeon examined the patient and in the same evening the 2nd surgery was performed, and the penetrating screw was carefully removed by doing a laminectomy and visualizing the dura directly, without causing any mechanical damage to the spinal cord. Thus, it would be wrong to allege that the screw was misplaced due to carelessness or ignorance of the surgeon, the counsel argued.
The commission observed that she was suffering from deformity in the back for 2 ½ years. The spinal anatomy was completely deformed cause of suffering to the patient. It was diagnosed as Congenital Kyphoscoliosis (Congenital Deformity of the spine) and progressive in nature.
On the question of the surgeon being an Orthopedicain and not a neurosurgeon, the commission noted, "Orthopedician may also provide spinal care including surgery to the patient. In the instant case the OP-2 though he was an Orthopaedic Surgeon had rich experience in spinal surgeries. It is not mandatory or any convention that both the Ortho and the Neurosurgeons shall be present during surgery."
The commission also noted that the patient's father and one relative are doctors. "They were aware of the congenital spinal defects and the available treatment options and its risks. The post-operative paralysis of the patient is a well-documented complication of spinal deformity due to anatomical malpositioning of the spine", it said.
The bench further noticed that at the Department of Orthopaedics of AIIMS, there are two C arm machines and both the machines were functional on the date of surgery of the patient.
" Thus we do not accept the Complainant's allegation that the spinal corrective surgeries were conducted without the help of the C-arm at AIIMS", added the commission.
Observing that the decision to remove the said screw was taken forthwith in consultation with the parents of the child, the commission added
the second procedure was carried out without loss of much time in presence of Neurosurgeon. Operatively no Dural injury was found. Therefore it was decided with the consultation of neurologist to place gelfoam surgical over the laceration in the Dura and the wound was closed. Methyl prednisolone was given as an established treatment protocol in acute spine cord injury and decongestants were given to prevent CSF leak. This cannot be construed as a short comings or medical negligence.
The commission clarified that the mode of treatment/ skill differs from doctor to doctor and the doctor is not liable for negligence if he performs his duty with reasonableness and with due care.
The commission also referred to the Supreme Court's verdict in the case of Dr. Laxmn B. Joshi vs Dr. Trimbak B Godbole & Anr. and said,
"The doctor owes certain duty towards the patient and the doctor can decide the method of treatment, which is more suitable for the patient. In the instant case, we find the treating doctors at AIIMS failed in the duty of care towards the patient."
The court concluded
the medical negligence is not conclusively established against Opposite Party No. 2 (Kyphosis & Scoliosys Unit HoD) and his team, who have performed the spinal deformity surgery with a reasonable duty of care.
Further, the court noting that the patient is pursuing MBBS at JIPMER, added, "We may add that we have sympathy with the patient for her Congenital Kyphoscoliosis deformity, however, sympathy cannot substitute for conclusive evidence of medical negligence. We are but happy to note that presently the patient (Complainant No. 1) is pursuing her MBBS at JIPMER, Pondicherry, and we wish her all success in life."
The commission advised the AIIMS authorities and stated
To take its Unit to the next level, as a systemic improvement, the Director, AIIMS may kindly consider enhanced integration of 'Orthopaedics' and 'Neurosurgery' in its said Unit, including by posting both 'Orthopaedics' and 'Neurosurgery' therein as well as working towards creating a speciality in its own right for 'Spinal Surgery', having knowledge in both 'Orthopaedics' and 'Neurosurgery'.
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