Is facial sensation loss after emergency surgery for a back abscess in a patient with lumbar disc (intervertebral disc) protrusion a breach of the standard of care?

Facial Sensation Loss After Emergency Back Surgery for Abscess with Lumbar Disc Protrusion

Facial sensation loss following emergency surgery for a back abscess in a patient with lumbar disc protrusion represents a breach of the standard of care, as this complication is not an expected outcome of proper spinal surgical technique and anesthesia management.

Mechanism of Facial Sensation Loss After Spinal Surgery

Facial sensation loss after spinal surgery is not a recognized or expected complication of properly performed lumbar spine procedures. This type of neurological deficit suggests one of several possible issues:

1. Anesthesia-related complications:

   • Improper positioning during prolonged surgery causing compression of facial nerves
   • Complications from airway management affecting cranial nerves

2. Surgical technique issues:

   • Migration of surgical intervention to inappropriate spinal levels
   • Vascular compromise affecting brain perfusion

3. Post-operative complications:

   • Unrecognized infection spreading to cranial structures
   • Medication-related adverse effects

Standard of Care for Emergency Spinal Abscess Surgery

The standard of care for emergency surgery for spinal abscess includes:

• Proper pre-operative assessment of neurological status
• Appropriate surgical planning with clear identification of affected spinal levels
• Intraoperative monitoring when indicated for high-risk procedures
• Proper positioning to prevent nerve compression
• Post-operative neurological assessment to detect new deficits promptly

Evidence Supporting Breach of Standard of Care

1. Anatomical considerations: Lumbar disc procedures and abscess drainage should not affect facial sensation, which is mediated by the trigeminal nerve (cranial nerve V) 1.

2. Recognized complications: The American Society of Anesthesiologists Practice Advisory on perioperative visual loss associated with spine surgery does not list facial sensation loss as a recognized complication of spine surgery 1.

3. Emergency procedure risks: While emergency procedures for spinal abscess carry higher risks of complications than elective procedures, these complications typically include wound infections, recurrent abscess, or worsening of existing neurological deficits related to the surgical site - not new cranial nerve deficits 1, 2.

4. Proper positioning requirements: The ASA and other societies recommend proper positioning during spine surgery to minimize complications, but facial nerve damage is not among the expected risks when proper positioning protocols are followed 1.

Potential Mechanisms for Facial Sensation Loss

Several mechanisms could explain facial sensation loss following spine surgery, all of which would represent deviations from the standard of care:

1. Improper positioning during prolonged anesthesia:

   • Facial compression against positioning devices
   • Excessive neck manipulation during intubation affecting cranial nerve pathways

2. Anesthetic complications:

   • Improper airway management techniques
   • Jaw thrust maneuvers performed incorrectly 1

3. Surgical technique issues:

   • Incorrect level identification leading to cervical rather than lumbar intervention
   • Vascular compromise during surgery affecting brain perfusion

4. Medication-related complications:

   • Adverse reactions to antibiotics used for abscess treatment
   • Neurotoxicity from anesthetic agents

Prevention Strategies That Should Have Been Employed

To prevent such complications, the standard of care requires:

• Proper patient positioning with padding of pressure points
• Appropriate airway management techniques
• Correct surgical level identification using imaging guidance
• Intraoperative neuromonitoring when indicated 1
• Post-operative neurological assessment to detect new deficits promptly

Conclusion

Facial sensation loss following emergency surgery for a back abscess in a patient with lumbar disc protrusion represents a breach of the standard of care. This outcome suggests either improper surgical technique, inadequate positioning during anesthesia, or failure to recognize and manage a serious complication. Such an outcome warrants thorough investigation to determine the exact cause and prevent similar occurrences in the future.