R M Redfern Consultant neurosurgeon Morriston Hospital Swansea

 M 60s  Amusement park owner  Admitted for operation for lumbar stenosis  The procedure involves removing bone and ligament from the lower spine to take pressure off nerves  3 levels in this case  A fairly routine procedure  Takes about 3 hours  Usually in hospital 4-6 days  70-80% chance symptomatic improvement

 Operation was proceeding satisfactorily but slowly due to tough bone  High speed air drill used  Drill bit snagged and jumped  Dural membrane torn  CSF rushed out  A ‘knot’ of nerve roots appeared

 What now?  Informed theatre staff and anaesthetist  Inspected nerves  – one torn rootlet  - remainder intact  Wondered whether to abandon operation  Separated nerves and covered dural tear  Completed decompression  Repaired dura with patch  Closed wound

 Explanation and apology to wife on ward  Took wife to recovery to examine together  Interviewed wife again  Explained priorities  To get through post-op period  To establish extent of damage  To deal appropriately with complications  To co-operate fully with negligence claim  Explanation and apology to patient on ward  Full explanation to nursing / medical staff  Reported incident to Medical Director  Documentation in case notes

 Paralysed left leg / weak right leg  Extensive numbness over legs  Perineal and scrotal numbness / anaesthesia  Lax anal tone  Pain in legs and at operative site

 Problems with infection  Clostridium difficile  Incontinence / Weakness / Numbness  Prolonged hospital stay  Other specialists involved  Urologist  Lower GI surgeon..... Gradual recovery – mobility / continence / independence

 Pre-operatively  Establish good Doctor-Patient relationship  Per-operatively  Take stock of situation / Don’t panic  Post-operatively  Openness from outset  Apologise  Admit fault and explain cause  Reassurance despite guarded prognosis  Inform medical staff / nursing staff / Med Director  Documentation in case notes  Provide regular follow-up

 Analyse cause  Discuss with other surgeons  Talk about experience to warn others  Use of high speed drill?  Potentially dangerous  Not absolutely contraindicated  Size / shape of drill bit [Another case in similar situation]