Spine surgery complications: Consumer court holds Hyderabad hospital, neurosurgeon negligent, orders Rs 20 lakh payout to US endocrinologist
Hyderabad: The District Consumer Disputes Redressal Commission (DCDRC), Hyderabad, recently held a city-based hospital and a consultant neurosurgeon guilty of medical negligence while conducting spinal surgery on a patient who developed complications after the procedure.
According to the case details, a tear occurred during the surgery and, allegedly, the repairs were not properly done, resulting in a persistent fluid leak from the surgical site.
Holding the treating hospital and the neurosurgeon liable for medical negligence, the Commission has directed them to pay Rs 20 lakh compensation and Rs 50,000 as costs of litigation.
Background:
The case dates back to March 2021, when the patient, an Overseas Citizen of India, a practising doctor as an endocrinologist in USA, came to India. After developing leg pain, the patient was diagnosed with two prolapsed intervertebral discs. After initial treatment at a nursing home, he was admitted to the treating hospital, where a neurosurgeon examined him and advised laminectomy and discectomy at level L4 and L5.
Post surgery, the neurosurgeon informed the patient that his dural sac tore during the surgery and a fat patch was put over it. The patient was instructed to lie down in the prone position and was also assured that the tear would seal within three days. Consequently, the patient was discharged.
However, allegedly, the patient/complainant kept feeling dampness at the surgical site in his lower back. Initially, the hospital changed the dressing; later, a plan was made for secondary suturing. The complainant alleged that it was not done, and the doctors allegedly applied Truseal without any intimation and/or explanation, and a dry dressing was placed on the surgical site. After the second discharge, the patient felt wetness over the dressing, and when he re-approached the hospital, the treating neurosurgeon allegedly covered the surgical site with Truseal, a thin film-like substance to prevent wetness of the dressing, and advised domiciliary care.
It was alleged that the doctor did not conduct radiological studies or did not make any effort to close the leak effectively. Instead, the doctor convinced the patient to leave for the USA. During the journey, the dressing site was constantly getting wet. After reaching the States, the complainant consulted a Neurosurgeon, who, after thorough investigation, advised an MRI of the lumbosacral spine. On reviewing the report, the doctor informed the complainant that the leak could be closed with 6 Prolene threads. Apart from that, about 150 cc of separated CSF fluid collection next to the tear and few fragments of disc and bone material near the tear were also noticed. Consequently, the patient underwent surgery for closure of the dural tear and the leak was closed, and the area became dry.
The patient alleged that around two years after the closure of the dural tear, he developed pain in his left leg all the way down from the hip to the toes. When he consulted a neurosurgeon, the doctor allegedly advised another surgery to correct several defects in his spine from the laminectomy done in India in March, 2021. He underwent another surgery. Thereafter, in 2024, the complainant visited the neurosurgeon, who informed him that the recurring pain was due to chronic arachnoiditis from a long-standing CSF leak and soaking of nerves in CSF fluid, resulting in clumping of the spinal nerve. The CSF leak from the tear was left in place for three weeks till it was closed in the USA. Following this, alleging medical negligence and deficiency in service on the part of the Hyderabad-based doctor and neurosurgeon, the patient filed a complaint.
On the other hand, the doctor and the hospital denied negligence. They submitted that complications such as CSF (Cerebrospinal Fluid) leak are known risks associated with laminectomy procedures and do not indicate negligence. According to them, the complainant had a history of seizures, an old cerebrovascular accident (CVA or stroke), and the complainant had undergone carotid endarterectomy. Given these factors, the patient was categorized as very high-risk for surgery. Despite the risks, the surgery was deemed necessary due to the severity of his pain and neurological deficits, they submitted.
They further pointed out that the complainant was also an active chronic chain smoker and submitted that smoking significantly increased the risk of spinal problems by accelerating degenerative disc disease through reduced blood flow to intervertebral discs, leading to faster degeneration and chronic back pain. Additionally, smokers experienced delayed spine healing after surgeries or injuries due to reduced oxygen and nutrient supply, further complicating the recovery.
According to them, intra-operatively, it was observed that the extruded disc was densely adherent to the dura (the outer membrane surrounding the spinal cord), which had become thin and ballooned out due to chronic compression. During the delicate process of separating the disc fragment, an unavoidable dural tear occurred. The disc fragment was successfully removed, and the torn dura was meticulously repaired using a fat graft (a biological patch to seal the defect). The surgical site was carefully closed in a watertight fashion to minimise postoperative complications.
They claimed that the CSF leakage was diagnosed in time; immediate investigations and treatment were undertaken without wasting any further time. Further, they submitted that the wound was re-evaluated multiple times and, since no active leakage was detected, the wound edges were sealed with Truseal.
The doctor and the hospital claimed that the complainant’s worsening condition was due to his own decision to take discharge at request and prematurely travelling from Hyderabad to the USA despite explicit medical advice to remain on bed rest.
Observations by Consumer Court:
After carefully perusing the record and considering the submissions and contentions by both the sides, the Commission noted that it was evident from the records that the complainant reported CSF leakage on 21.03.2021 and secondary suturing was noted as ‘plan’ to address the tear. Further, the discharge summary dated 21.03.2021 and 24.03.2021 mentioned that the CSF leakage was addressed by applying Truseal.
The Commission observed that the discharge summary did not mention discharge at request, as claimed by the hospital and doctor. From the treatment copy of the USA doctor, it was observed that the neurosurgeon abroad had observed the CSF leak. The MRI conducted in 2023 also revealed that the previously seen paraspinous postoperative fluid was resolved after the suturing by the USA-based surgeon to address the CSF leakage.
"In the case at hand, the opposite parties, except stating that the complainant’s attempt to question the surgical technique is entirely without merit, has not submitted rebuttal to the opinion... In the report, Dr *** at Research Neuroscience Institute, has mentioned that the complainant’s history is significant for multiple lumbar surgeries for decompression as well as dural repair after prolonged CSF leak. In the written statement and evidence affidavit of opposite parties, there is no whisper regarding change of plan from secondary suturing to application of ‘Truseal’ on the wound. There is no iota of material to show that the opposite parties have informed about the change in the plan to the complainant. The opposite parties, except mentioning about the smoking habits of the complainant in the written version and evidence affidavit filed before us, have not mentioned the same in the discharge summary," observed the Consumer Court.
It further noted that it was mentioned nowhere that the CSF leak was due to the complainant's smoking habits. The Commission also noted that the surgery was performed in 2024 after getting clearance from the pulmonologist.
"The medical literature relied by the opposite parties contradicts the procedure adopted by the opposite party No. 2 in addressing the CSF leakage. None of the tools used to know about the CSF leak (as mentioned in the literature) have been noted in either the doctor’s notes or the discharge summary. Further, the medical literature/journal confirms that using a sealant strictly as standalone measure for a tear has a higher failure rate than combining it with sutures," observed the Commission.
The Consumer Court observed that negligence is the breach of a duty caused by omission to do something which a reasonable man guided by those considerations which ordinarily regulate the conduct of human affairs would do, or doing something which a prudent and reasonable man would not do.
"Negligence becomes actionable on account of injury resulting from the act or omission amounting to negligence attributable to the person sued. The essential components of negligence are three: duty, breach and damage...The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person in those circumstances would have chosen or followed," it observed.
Referring to the evidence submitted by the complainant, the Commission concluded that the evidence concluded that the treating neurosurgeon at the Hyderabad-based hospital had failed to properly evaluate the CSF leak issue reported within 4 days of the surgery and he did not give any explanation for changing the plan from suturing to application of Truseal.
"The suture procedure by Dr *** for addressing CSF leak along with literature filed by opposite parties establish that the opposite party No. 2 (consultant neurosurgeon) has failed to adhere to the standard procedure adopted universally in dural damage; more particularly, in the case of high risk and elderly patients. The material evidence on the record placed before us establishes that the opposite party No. 2 is deficient in providing post-operative care and is negligent in attempting to close the tear during the second admission on 21.03.2021. The opposite party No. 1 hospital is vicariously liable for the negligence and deficiency in service of its doctors. Therefore, we are of the considered opinion that the conduct of opposite parties No. 1 & 2 amounts to medical negligence," held the Commission.
"In the case at hand, the opposite parties have failed to prove that reasonable and accepted steps have been taken to address the known complication in a high risk patient. Further, there is nothing on the record to show that the change of plan while addressing the CSF leak has been informed to the complainant before applying the Truseal. It is not the adverse outcome that has to be seen in the present case but the failure to take reasonable care while addressing the known complication. The evidence on the record establishes that the opposite party No. 2 has failed to take reasonable care owed and accepted by him while taking the case of the complainant...Admittedly, the complainant has been suffering due to prolonged CSF leak after the first surgery done in March, 2021. Hence, the complainant is entitled for reasonable compensation with costs," it concluded.
Accordingly, the Commission directed the hospital and neurosurgeon to pay Rs 20 lakh compensation and Rs 50,000 as costs of litigation. "Looking to the facts and circumstances of the present case and the age of the complainant, we are of the considered opinion that awarding compensation of Rs. 20,00,000/- (Rupees Twenty Lakhs Only) for the deficiency in service and costs of Rs. 50,000/- (Rupees Fifty Thousand Only) will meet the ends of justice," stated the order.
To view the order, click on the link below:
