Risk of nerve injury

A 57-year old male patient presented to his vascular surgeon, an MDU member, with a long-standing history of bilateral varicose veins. He had undergone ligation and stripping procedures 10 years previously.

The patient reported increasingly troublesome heaviness and aching in both limbs. The symptoms were attributed to long-standing venous insufficiency. With a view to surgical treatment, our member advised a duplex scan to confirm the extent of the patient's problem. They discussed likely surgical management in light of the patient's earlier procedures and talked in-depth about general surgical risks, including potential damage to vasculature or nerves.   

Nine months following surgery, the patient returned to see the surgeon again, reporting electrical shock pain, preceded by numbness on the outside border of the right foot.

It was the surgeon's routine practice to discuss scan results, her surgical recommendations and the possible complications of such surgery over the telephone with the patients. Her secretary would then follow up with a call several days later to arrange the hospital admission. The patient later suggested that he had not been telephoned in this manner but the hospital switchboard log had recorded calls to the correct number, consistent with the consultant following her usual practice. 

The patient's scan demonstrated ongoing reflux in both long saphenous veins, but no other pathology. As recommended, the patient underwent a ligation and stripping procedure on both long saphenous veins. He was formally consented earlier on the day of the surgery, when the risks and potential complications were reiterated before he signed a consent form. The surgery proceeded uneventfully and no problems were reported in the early or intermediate post-operative period. 

Nine months following surgery, the patient returned to see the surgeon again, reporting electrical shock pain, preceded by numbness on the outside border of the right foot. The consultant suspected a neuropraxia (nerve bruising), which would eventually resolve. The symptoms persisted however, curtailing the patient's recreational activities.

The patient later brought a clinical negligence claim. He alleged that he had been inadequately consented regarding the risks of the surgery, particularly nerve injury. Had he known the risks, he stated, he would have deferred surgery until his venous symptoms became more troublesome; a later procedure would not have resulted in permanent nerve injury. The patient's treating neurologist had performed nerve conduction studies, demonstrating multiple pathology, a sural nerve abnormality and a background polyneuropathy. 

The MDU obtained independent expert opinion from a surgeon and a neurologist regarding the allegations. The surgeon was supportive, stating that the member had acted throughout in accordance with a reasonable body of surgeons. The patient had understood the risk of nerve injury and proceeded on that basis. The neurologist advised that, while the claimant's symptoms were compatible with a nerve injury, injury to the sural nerve seemed inexplicable, given the nerve's position relative to the long saphenous vein. 

The MDU subsequently served a formal letter of response, denying any breach of duty or liability and highlighting the clear inconsistency between the positioning of the operative site and the allegedly damaged nerve. The claimant withdrew his claim.

Dr Lucy Baird
Senior medical claims handler

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