Patient: 35 year old with sudden onset of severe back and bilateral leg pain associated with bowel and bladder dysfunction. Considered to be a surgical emergency. Surgeon approached the large intraspinal mass (red dot) compressing the cauda equina through a standard partial laminotomy approach. Surgeon noted unusual “ligamentum flavum” and then encountered freely sequestered disc material. He had inadvertently transected the patient’s compressed cauda equina. This patient was rendered permanently paraplegic.
This example of a horrific surgical misadventure makes the point of the importance of adequate surgical exposure and visualization. This surgeon should have performed adequate laminectomy so that he could visualize “normal” landmarks. The major disadvantage of “microsurgical” operative procedures is thinking “small” when thinking “large” is more appropriate.
The single most common failure relates to obtain adequate exposure and decompression in the treatment of lateral spinal stenosis. Failure to adequately decompress impaired nerves (so that they are ballottable and no longer under tension) represents the single most common reason for the “failed back surgery syndrome.”