CASE 392

A 44-year-old man with chronic low back pain underwent an elective anterior lumbar interbody fusion (ALIF) performed by two surgeons. The man had a prior history of abdominal surgery but was in otherwise good health. Although the surgery went well with no recognized complications, the man developed a complex postoperative infection and was found to have a left ureteral transection. A portion of a severed ureteral stent was identified and retrieved during reoperation, and the patient required a percutaneous nephrostomy tube before undergoing two complex ureteral reconstructions. He continues to suffer from chronic abdominal pain.

Elite Medical Experts’ Case Strength Score™

Elements of Negligence: 8
Case Economics: 8
Subjective Appeal: 8

Case Strength Score™ Interpretation:

CSS ≤ 16:
    Clearly defensible case. Plaintiff theory is critically flawed.
CSS 17-20: Defense likely to prevail. Plaintiff may explore cautiously.
CSS 21-23: Strategic elements favor plaintiff. Moderate risk for defense.
CSS 24-30: Strong plaintiff case. Defense at high risk of loss.

Total Score


This case warrants further exploration.

Anterior lumbar interbody fusion (ALIF) is performed far less commonly than other (e.g. posterior) spine surgery approaches, and carries a higher rate of complications. Since ALIF requires an abdominal approach, most spine surgeons work with a second surgeon (e.g. General Surgery or Vascular Surgery) who begins the case by exposing the spine beneath the abdominal contents. During this approach, the assisting surgeon must identify and preserve all abdominal structures, including the ureters. Ureteral preservation is facilitated by direct visualization often in conjunction with stenting. The stents, which are placed into each ureter via the urinary bladder, allow both surgeons to palpate (feel) the ureters and confirm their location during surgery. Some stents have high-intensity transillumination to literally light the ureters as a means of averting injury. Once the abdominal structures and ureters have been properly identified and protected, the spine surgeon may approach the vertebral column with relative safety.

In the current case, one of the ureters had an unrecognized transection during surgery. This is extremely uncommon since the ureters were supposed to be identified and preserved. Although ureteral injuries often occur when the ureters are unmarked, it is extremely unusual to sever a marked ureter and not recognize the mistake intraoperatively. The failure to recognize transection was compounded by the fact that the surgeon left a portion of the severed ureteral stent in the patient. This is also extremely unusual since the surgical team should have recognized that only part of the stent was retrieved from the patient. The Elements of Negligence are strong [8] since the injury should have been prevented and was also unrecognized despite several opportunities. The Subjective Appeal of the case is favorable [8] since the issues are understandable and will resonate in a relatively simplistic level with the trier of fact. The Net economics are also favorable [8] given the significant damage and ongoing symptoms. For all of these reasons, this case would be difficult to defend and warrants a the Case Strength Score of 24.

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