Wounding With Intent Biodun Ogungbo_ MBBS, FRCSEd, FRCS(SN), MSc

Demand for surgery
The management of spine patients can be easy or complex depending on the condition presented and the options for management. This was brought to light for me recently when I saw a woman with severe back and bilateral leg pains. She demanded surgical treatment and therefore freedom from pains. Indeed, she had been offered surgery at another facility. She looked in real trouble, but the clinical examination was normal. Further, her MRI scan did not show a significant lesion responsible for the pains.
Unfortunately, though she was in severe pains, surgery was not the answer.

You see, we as spine surgeons require a specific target for surgical intervention. We need to know where we are going to do the operation, what we will do when we get there and finally, that the exercise will be justified, resulting in good outcome for the patient.

High risks
Spine operations have high risks and need careful consideration. We only operate on patients who are deserving, who have an operable condition and in whom the benefits outweigh the risks of operation. This is the ideal and best practice! In this regard, patients who are already well, are not surgical candidates. Since the operation is to make them better!
If you are already better, why take the risk.
We certainly cannot achieve better than nature. Patients with no surgical targets are also not good candidates for surgery since even after operation, their problems may persist. This should therefore be spelt out clearly to patients and any request for surgery should be denied. These patients can be referred to other specialists such as pain specialists, neurologists, physiotherapists and acupuncturists for other treatments apart from surgery.

Patients’ choice
The patient has a choice. The patient can choose to believe you or not. If not, they can certainly go shopping for another surgeon. Here therefore lies the crux of the matter.

Wounding with intent
There have been a few surgeons sent to jail for performing unnecessary operations on patients. Some in the USA and one recently in the UK. The specialist must be above reproach in offering surgical care and must be able to justify that the benefits outweigh the risks. For there are significant risks attached to operations especially with anesthesia and the actual procedure.
There is also litigation!

Breast surgery
The British breast surgeon, Ian Paterson, was recently found guilty of “wounding with intent” after operating on patients unnecessarily. He has now been sentenced to 15 years in jail. The prosecution argued that Mr Paterson greatly exaggerated and, in some cases, he even invented the risk for breast cancer, and that the surgeries were unnecessary.
In some cases, a biopsy would have sufficed.

Spine surgery
Aria Sabit, a spinal surgeon admitted to unnecessary as well as fake operations, and was sentenced to a prison term of 235 months — almost 20 years — in a federal district court in Detroit, Michigan. Dr Sabit performed a spree of unnecessary surgeries as well as legitimate ones in which he overloaded patients with hardware. Prosecutors described some of the operations as “plain butchery.” Nearly 30 of his patients in California — operated on in just an 18-month stretch — later sued him for malpractice. During those 18 months, he accounted for 71% of all patients who were unexpectedly readmitted to hospital following surgery.
Several died from complications, according to whistle-blowing colleagues.

Another one
A Dallas jury sentenced a neurosurgeon to life in prison after it heard from over a dozen patients who testified that Christopher Duntsch seriously maimed them while they were under his knife. He was accused of crippling four patients and causing the deaths of two others between July 2012 and June 2013.
Th e 46-year-old was arrested in July 2015 on five aggravated-assault charges. However, his trial only focused on a charge of injury to an elderly individual — a first-degree felony where someone “intentionally, knowingly, recklessly, or with criminal negligence” injures an elderly person. Another doctor, Dr. Robert Henderson, who treated the patient after her botched surgery said Duntsch had “done virtually everything wrong.
Dr. Robert Henderson found implants placed in muscle instead of on bone, a screw drilled into her spinal cavity and a nerve root that had been amputated. “It’s as egregious as you can imagine,” Henderson said.

It is vitally important for spine surgeons to have the appropriate level of skill for the diagnosis and treatment of spine patients. The ability to offer the right treatment which may not be surgical is inherent in that skill set. Knowing when not to operate is perhaps the most important skill of all. These cases are sobering examples for us surgeons!

Operating without regards for pecuniary gains and self-aggrandizement should be a given to maintain good outcomes for patients. The operations should also be accomplished with competence! Surgeons should be well trained and only perform operations for which they have the specific skills and required equipment.
NB: Patients who go to certain hospitals because the surgeon is white skinned maybe doing themselves a huge disservice. The skin colour does not relate to competence!

Dr Biodun Ogungbo is a UK General Medical Council Registered Specialist in Neurosurgery and Nigeria Medical and Dental Council registered Surgeon. He has extensive surgical repertoire in elective and emergency neurosurgery procedures.

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