Litigation risks despite guideline adherence for acute spinal cord injury: time is spine

Neurosurg Focus. 2020 Nov;49(5):E17. doi: 10.3171/2020.8.FOCUS20607.


Objective: Current guidelines do not specify timing for management of acute spinal cord injury (aSCI) due to lack of high-quality evidence supporting specific intervals for intervention. Randomized prospective trials may be unethical. Nonetheless, physicians have been sued for delays in diagnosis and intervention.

Methods: The authors reviewed both the medical literature supporting the guidelines and the legal cases reported in the Westlaw and Lexis Advance databases from 1972 to 2018 resulting in awards or settlements, to identify whether surgeons are vulnerable to litigation despite the existence of guidelines not mandating specific timing of care.

Results: Timing of intervention was related to claims in 59 (36%) of 163 cases involving SCI. All 22 trauma cases identified cited timing of intervention, sometimes related to delayed diagnosis, as a reason for the lawsuit. The mean award of 10 cases in which the plaintiffs' awards were disclosed was $4,294,384. In the majority of cases, award amounts were not disclosed.

Conclusions: Because conduct of a prospective, randomized trial to investigate surgical timing of intervention for aSCI may not be achievable, evidence-based guidelines will be unlikely to mandate specific timing. Nonetheless, surgeons who unreasonably delay intervention for aSCI may be at risk for litigation due to treatment delay. This is increasingly likely in an environment where "complete" SCI is difficult to verify. SCI may at some point be recognized as a surgical emergency, as brain injury generally is, despite a lack of prospective randomized trials supporting this implementation, challenging the feasibility of the US trauma infrastructure to provide care for these patients.

Keywords: AIS = American Spinal Injury Association Impairment Scale; ATCCS = acute traumatic central cord syndrome; CNS = Congress of Neurological Surgeons; SCI = spinal cord injury; aSCI = acute SCI; aSDH = acute subdural hematoma; intervention; litigation; spinal cord injury; surgical decompression; timing.

Publication types

  • Review

MeSH terms

  • Guideline Adherence
  • Humans
  • Prospective Studies
  • Spinal Cord Injuries* / surgery
  • Spine
  • Surgeons*