The first alarm bells around the spinal surgery service in Temple Street children’s hospital in Dublin went off more than a year ago, when two serious postoperative surgical incidents were reported. Shortly after, staff members raised concerns about outcomes from spinal operations on children with spina bifida.
In response, Children’s Health Ireland (CHI) started an internal review but also commissioned experts from Boston children’s hospital to review the programme. Their report has not been published but has been “consolidated” into the overall report published by CHI on Monday, according to the Health Service Executive.
A decision was also taken to pause the most complex spinal surgery, kyphectomy, for patients with spina bifida until the results of the reviews were known.
Ireland has one of the highest incidences of spina bifida in the world – about one in 1,000 children are born with the condition and 500 children are living with it. That means demands for quality healthcare and spinal surgery are higher here than in other countries.
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Spina bifida is a birth defect in which an area of the spinal column doesn’t form properly. Severity can vary but impact can include neurological and muscle weakness.
Scoliosis and kyphosis both involve an undue curvature of the spine; scoliosis to the side and kyphosis outwards.
The provision of spinal surgery for children with spina bifida was consolidated in Temple Street from 2014 on, though a small number of families whose children were being treated in Crumlin children’s hospital chose to stay there for their care.
Delays in spinal surgery have been a source of acute embarrassment for successive governments. Time and again, the gruesome spectacle of young children suffering spinal deformation worsened by delays in treatment has shamed politicians into promising an end to waiting lists for young scoliosis patients.
But targets have not been met. While resources were increased, demand also rose. The Covid-19 pandemic disrupted services and promised extra staff and resources have proven frustratingly slow to deliver. The much-promised fifth operating theatre in Temple Street has yet to open.
Last year, Minister for Health Stephen Donnelly allocated €19 million for children needing orthopaedic surgery. The number of spinal surgeries carried out at Temple Street in 2022 increased to 124, up from 93 in 2017.
The review looked at 16 patients who underwent complex spinal surgery at Temple Street, six of whom had had a kyphectomy. It found the rate of complications in Temple Street was higher than that observed in published articles from other international sites. But the small number of cases involved renders detailed comparisons impossible.
According to the published literature, 45 per cent of children undergoing kyphectomy since 2000 required an unplanned return to the operating table and almost 2 per cent died.
CHI’s analysis of 16 cases at Temple Street found 13 (81 per cent) required further unplanned surgery. One of these patients died after multiple procedures and this death is currently being investigated.
The infection rate for the 16 cases was 73 per cent and the rate of wound complication requiring further surgery was 75 per cent. Nine of the cases (56 per cent) had mechanical complications of metalwork requiring its removal.
Could the delays in treatment and the pressure to increase the number of procedures carried out be factors behind the increased rate of complications? The CHI report says the waiting time for surgery at Temple Street “did not appear” to have a negative impact on the increased rate of postoperative complications. But it goes on to warn that “resources need to be available” if this high-complexity surgery is to continue at the hospital.
An already grave situation has grown even more serious with the admission by the HSE that “unauthorised devices” were used in at least two further patients. The Ditch website reported on Friday that these devices were compression springs not designed for surgical use.
The HSE has identified a single consultant at Temple Street as the primary focus of the external review it has ordered. The consultant continued to perform complex spinal surgery until last November, months after staff raised concerns. His case has been referred to the Medical Council.
Complex spinal surgeries at Temple Street have been paused now for more than a year. The report says work has begun on transferring complex patients to other surgeons in CHI. Some children may be transferred for treatment to other countries.