A surgeon must navigate many questions and considerations prior to performing spine surgery, one of which is whether to take an anterior or posterior approach. Although treatment of many spinal conditions can lead to positive results, spine surgery can also lead to complications ranging from infection and chronic pain to paralysis and death. When a patient suffers harm, the judgment and decisions of the surgeon, including how he or she elected to access the spine during surgery (anteriorly or posteriorly), may come under scrutiny in a medical malpractice lawsuit.
Anterior vs. posterior approaches to spine surgery
In simple anatomical terms, anterior refers to the front of the body, whereas posterior refers to the rear of the backside. The difference between anterior and posterior surgery is how the spine is accessed. For example, in anterior cervical spine surgery, the surgeon accesses the spine through the front of the neck. Similarly, the anterior approach to the thoracic spine is through the chest while the anterior lumbar spine is accessed through the abdomen. In all anterior techniques, the surgeon approaches the spine from the front of the body, with the patient lying face-up (supine). In all posterior surgeries, the surgeon approaches the spine from the backside while the patient lies face down (prone).
While all posterior spine surgeries can be performed by a single spine surgeon, anterior approaches through the chest and abdomen often require a second surgeon in order to gain access to the spine. For example, in anterior lumbar fusion, a general surgeon or vascular surgeon typically opens the abdomen and navigates a surgical path to expose the spine for the spine surgeon. This poses risks to intraabdominal structures that would not be encountered during posterior spinal surgery, and it also means that when complications occur, there may be more than one party at fault.
Despite the variations in techniques and surgical approaches, there is no defined consensus on a recommended approach, according to the authors of a 2017 study discussing the impact of surgical approach on intra- and post-operative complication rates that appeared in the Journal of Spine Surgery.
The study examined the medical records of 443 adult spine deformity patients undergoing elective spinal fusion at a major academic institution between 2005 to 2015. Of those 443 patients, 96 (21.7 percent) had anterior surgery only, 225 (50.8 percent) had posterior only, and the remaining 122 (27.5 percent) had a combination of anterior/posterior approaches. The researchers reported that patient demographics and comorbidities were similar across all groups. When comparing all three approach options, the posterior approach had significantly higher rates of estimated blood loss, blood transfusions, and intraoperative dural tears, which is a common complication of spine surgery. The combined approach had a significantly longer operative time than either option on its own. There was no significant difference in the rate of 30-day readmissions between the cohorts. The researchers concluded that their findings suggest posterior approaches to spinal fusion “may lead to a higher incidence of complications compared to anterior or combined anterior/posterior approaches.”
However, authors of a study published in the Journal of Clinical Neuroscience in 2015 concluded that anterior surgical approaches “as currently practiced in the USA” may be associated with higher postoperative morbidity and reoperation rates than posterior fusion approaches. The study examined a database of 10,941 adults who underwent spinal fusion surgery from 2000 to 2009. Of these, 7,460 (68.2 percent) and 3,481 (31.8 percent) had posterior and anterior fusion, respectively. Anterior fusion patients had a higher two-year reoperation rate, although differences became insignificant at maximum follow-up. They were also more likely to experience complications and had greater levels of postoperative health utilization. Common complications unique to anterior cervical surgery include airway loss, esophageal damage, and thyroid injury. Complications of anterior lumbar surgery that cannot occur from a posterior approach include intraabdominal injuries of the ureters, aorta, and bowel.
Reasons for medical malpractice suits in spinal surgery
Spinal surgery carries a significant risk of medical malpractice claims due to a relatively higher risks of serious complications and poor outcomes when compared to other surgical procedures. A 2011 study published in the New England Journal of Medicine said neurosurgeons faced a 19.1% annual risk of a claim, higher than any other specialist. When a lawsuit is filed in connection to spine surgery, the most common allegations include a lack of informed consent, failure to diagnose and treat, performing negligent and/or unnecessary surgery, spoliation (e.g. falsifying notes/hospital records) and failure to provide adequate intraoperative neural physiological monitoring, according to a 2020 article in the Journal Surgical Neurology International.
However, a poor outcome alone does not constitute malpractice; claimants must show that the standard of care was not met, and that this failure caused harm to the patient. Ultimately, it is the trier of fact who will determine whether there was preoperative, intraoperative, or postoperative malpractice, and their conclusion will be based on testimony establishing what a competent specialist in the field would have done under the same or similar circumstances.
Disagreements over how to proceed
As anyone who has received conflicting opinions from medical practitioners can attest, competent specialists often disagree about the best ways to proceed in a given situation. In a 2013 study published in Surgical Neurology International, the study’s author, a spine surgeon, evaluated 183 patients who came for a second opinion after their first-opinion surgeons told them they needed spine surgery. The second-opinion surgeon documented that the previous spine surgeons recommended unnecessary surgery in 60.7% of the cases, while in a third (33.3%) of the cases, the “wrong” surgery was indicated. “Unnecessary” operations were defined as those recommended for pain alone or those without focal neurological deficits or significant radiographic abnormalities. “Wrong” operations were defined as including those that were considered overly extensive or that were performed from the wrong access route.
An acknowledged major limitation of the study was that it relied on one spine surgeon’s subjective opinion to determine if the original opinions were wrong. But the study does highlight the fact that when it comes to decisions regarding spine surgery, there is room for disagreement among competent specialists. The same disagreements may occur when electing to perform anterior or posterior spinal surgery. By understanding the different approaches and inherent risks, attorneys can ask targeted questions, and make better-informed decisions, about their cases.
