Who is liable for the L2 chance fracture that occurred when a 60-year-old female with a history of lumbar fusion (previous spinal surgery with rods and screws) and nephrectomy (kidney removal) for kidney cancer was positioned in a lateral decubitus position and the bed was flexed during a medical procedure?

Liability for L2 Chance Fracture During Patient Positioning

The medical team responsible for patient positioning during the nephrectomy procedure is liable for the L2 chance fracture that occurred when the patient was placed in lateral decubitus position and the bed was flexed.

Understanding Liability in Patient Positioning

Patient positioning during surgical procedures is a shared responsibility of the entire surgical team, with specific roles and responsibilities distributed among different team members. When a patient with a history of spinal instrumentation suffers a fracture during positioning, liability typically falls on those responsible for positioning.

Key Factors in This Case:

1. Pre-existing Risk Factors:

   • 60-year-old female with previous lumbar fusion with rods and screws
   • History of spinal instrumentation (even if plates were removed 10 years ago)
   • These factors should have flagged the patient as high-risk for positioning injuries

2. Mechanism of Injury:

   • Lateral decubitus positioning combined with bed flexion
   • This positioning created hyperflexion forces on a previously instrumented spine
   • Chance fractures typically occur from flexion-distraction forces

Specific Responsibilities and Liability

Operating Room Team Responsibilities:

The Association of Anaesthetists guidelines 1 clearly state:

• "Certain patients, such as those with proven or suspected unstable vertebral fractures, require extra precautions in order to position them safely."
• "This will often involve specialist pieces of equipment and staff members trained in their use."
• Patient positioning is a shared responsibility requiring coordination among team members

Standard of Care Violation:

1. Failure to Identify Risk:

   • The team should have identified the patient's spinal fusion history as a risk factor
   • Previous spinal instrumentation alters biomechanics and creates stress points

2. Inadequate Positioning Technique:

   • Guidelines specify that "knowledge and training in how to operate the theatre table is essential" 1
   • The combination of lateral decubitus position with bed flexion created excessive stress on the previously fused spine

3. Insufficient Precautions:

   • Special positioning considerations should have been implemented for this high-risk patient
   • Mechanical theatre tables "put patients at risk" and require proper training to operate 1

Legal Framework for Liability

From a medical-legal perspective, establishing liability requires demonstrating:

1. Duty of care: The surgical team had a duty to safely position the patient
2. Breach of standard of care: The team failed to take appropriate precautions for a patient with previous spinal instrumentation
3. Causation: The positioning directly caused the L2 chance fracture
4. Harm: The patient suffered a significant spinal injury

In medical negligence cases, the standard of care is understood to be the "reasonable and ordinary care, skill, and diligence" that physicians and surgeons "in good standing and in the same general line of practice" would exercise in similar circumstances 1.

Risk Mitigation Strategies

To prevent such injuries in future cases:

• Thorough pre-operative assessment of patients with spinal instrumentation
• Clear communication about positioning risks among all team members
• Use of specialized positioning equipment for high-risk patients
• Minimizing flexion forces on previously instrumented spines
• Implementation of a "second time-out" procedure specifically for positioning 2
• Documentation of positioning decisions and rationale

Conclusion

The medical team responsible for patient positioning during the procedure bears liability for the L2 chance fracture. The standard of care requires special precautions for patients with previous spinal instrumentation, and the combination of lateral decubitus positioning with bed flexion created excessive stress on the spine, resulting in fracture. This represents a preventable complication that occurred due to inadequate risk assessment and positioning technique.