Introduction: In medical malpractice, spine surgery is a highly litigated field of medicine. However, there are few studies that have described characteristics of spine medical malpractice litigation and even fewer studies that have identified predicators of medical malpractice outcomes ensuing spine surgery. Currently the literature does not contain any specific analyses on legal outcomes between different types of spine surgery. This study involved a comparison of medical malpractice outcomes between different types of spine surgery and recognizing predictors of legal outcomes.
Methods: Using the national medicolegal database, Westlaw, spine surgery medical malpractice verdicts and settlements from 2012-2018 were obtained. Criteria for study inclusion required that cases involve complaints related to surgery and post-operative complications. Cases that were excluded from the study involved complaints related to negligent pre-operative diagnosis and/or management prior to surgery. Factors that were noted for each case include: patient demographics, procedure type, reasons for litigation, type of injury, and legal outcomes. A single variable analysis was done to identify predictors of legal outcomes and higher verdict amounts.
Results: A total of 562 legal cases were examined after excluding copies, extraneous cases, or cases with insufficient information, 199 of the cases were used for analysis. Cases were classified based on instrumentation (instrumented: 111, non-instrumented: 77), spinal levels (single level: 85, multi-level: 82), procedure (decompression: 67, fusion: 34, decompression with fusion: 74, other: 16). The verdict was in favor of the defendant in 145 (73%) of the cases. Of the remaining cases, 33 (17%) reported a plaintiff verdict and 21 (11%) resulted in a settlement. The most common reasons for litigation in non-instrumented cases were intra-operative error (43%), failure to obtain informed consent (36%), and improper post-operative management (36%); for the instrumented cases, the most common reasons for litigation were improper post-operative management (38%), improper hardware placement (37%), and failure to obtain informed consent (26%). A similar defense verdict was yielded regardless of instrumentation, procedure type, spinal levels, dural tear, and infection; conversely, cases were less likely to result in a defendant verdict if the patient suffered post-operative cauda equina syndrome (41% vs 77%, p=0.001) or other serious injury (paraplegia, quadriplegia, anoxic brain injury, or death) (62% vs 77%, p=0.03). Neurosurgeons were less likely to successfully defend the medical malpractice case than orthopedic surgeons (67% vs 85% defendant, p=0.005). Median payments for plaintiff verdicts and settlements was $1.3 million. Of note, the median payouts were significantly higher for cases involving multi-level spine surgery (median: $1.88 vs $0.79 million, p=0.04) when compared to single-level spine surgery; in all other cases (instrumentation, procedure type, surgical site infections, dural tears, cauda equina syndrome, serious injury, and defendant specialty) median monetary awards were relatively similar and not statistically significant predictors of higher median verdict amounts (p>0.05).
Conclusion: Intra-operative errors are among the most common reasons for medical malpractice litigation following spine surgery. Overall, spine surgeons are likely to successfully defend against legal cases. However, our findings show that court case outcomes and monetary awards can vary significantly depending on the level of spine surgery, alleged injury, and defendant medical specialty. In particular, multi-level spine surgery, cauda equina syndrome, or serious injury were significantly more likely to result in unfavorable outcomes for the defendant surgeons. By reducing intra-operative errors and improving the monitoring and management of post-operative complications, surgeons will be able to optimize care of patients, all while reducing the risk of litigation and healthcare costs.