Leake v Targett

A surgeon who adopts a wait and see approach after postoperative imaging reveals displaced spinal cages must maintain heightened vigilance and carefully monitor the patient, including by repeat imaging. The decision whether to undertake early revision surgery requires a risk-benefit assessment addressing the patient’s symptoms and clinical progress, the stability of the spinal construct, the possibility of further movement or clinical damage, the advantages of early revision, and the risks of intervention. A failure to recognise significant cage displacement may make subsequent failures to record, communicate, warn and investigate causally negligent. Where earlier revision would probably have avoided the injury, liability follows.

The claimant underwent instrumented spinal fusion performed by the defendant, a consultant orthopaedic surgeon. Postoperative symptoms included pain, numbness and altered sensation in both legs. X-rays taken shortly after the operation showed displaced intervertebral cages, but the defendant failed to recognise the displacement. He discharged the claimant and continued conservative management without recording cage movement, warning the claimant, informing the general practitioner or arranging repeat x-rays.

By August 2000 the claimant remained symptomatic and further imaging revealed substantial cage displacement. Revision surgery was undertaken, but the claimant suffered a left foot drop. The central questions were whether the defendant had negligently interpreted the March x-rays and, if so, what treatment he would probably have undertaken and whether earlier revision would have avoided the foot drop.

1. Liability. Judgment was entered for the claimant in the agreed sum of £60,000.
2. The defendant had failed to competently interpret the March postoperative x-rays. He should have recognised that at least two cages had prolapsed. The court rejected his evidence that he had noticed one cage and consciously adopted a reasonable monitoring policy.
3. A wait and see approach could accord with the practice of a responsible body of spinal surgeons, but it required heightened vigilance, careful clinical monitoring and repeat x-rays. The defendant’s failure to record cage displacement, inform the claimant’s general practitioner, warn the claimant about relevant symptoms and arrange repeat imaging was explained by his primary failure to interpret the x-rays competently.
4. The appropriate decision required a risk-benefit analysis. Relevant considerations included the claimant’s symptoms and clinical progress, the efficiency of the spinal construct, the possibility of further cage movement, the risk of increased discomfort or neurological damage, the desirability of earlier revision, and the possibility that early surgery might jeopardise improvement. The risks of infection and the need to allow approximately 7–10 days for neural blood supply to re-establish were also relevant.
5. On the balance of probabilities, competent interpretation would have led to revision surgery in late March or early April 2000, after adequate time for the neural blood supply to recover. Both spinal surgery experts agreed that surgery before the end of April would have avoided the foot drop. The defendant’s negligence therefore caused the claimant’s injury.