Abstract
Introduction Intradural spine procedures carry substantial neurological risk and technical complexity, yet their associated medicolegal landscape remains poorly characterized. Improved understanding of their litigation patterns may help inform patient counseling, perioperative communication, and risk-reduction strategies.
Methods A retrospective analysis was conducted of malpractice litigation involving common intradural spine procedures: myelomeningocele repair, tethered cord release, and intradural mass resection, using the Westlaw legal database. Inclusion required that one of the specified procedures was central to the litigation and had been performed. Data were extracted on plaintiff demographics, allegations, and outcomes.
Results From an initial review of 417 cases, 22 met the inclusion criteria. Most cases (63.6%) occurred after 2005. The estimated annual litigation frequency was 1 per 1200 intradural mass resection procedures, 1 per 2950 tethered cord release procedures, and 1 per 4600 myelomeningocele repairs. Common allegations included improper informed consent (63.6%) and procedural error (50.0%). Physicians were named in 86.4% of cases, followed by hospitals or clinics (72.7%) and government entities (27.3%). At the time of review, only 4.5% had resulted in a plaintiff verdict. The mean time from surgery to legal resolution was 70.2 months.
Conclusion Intradural spine litigation represents an underexplored area of medical malpractice. Informed consent and procedural error were most frequently cited, highlighting the potential benefit of improved preoperative communication and surgical protocols. Intradural mass resection had the highest estimated annual frequency and involved only adult plaintiffs, reflecting possible differences between adult and pediatric populations, such as differences in baseline functional status and the role of guardians in pediatric claims.
Introduction
Spine surgery frequency has increased steeply in the past 40 years,1–3 with an estimated 1.6 million procedures performed annually.3 Despite these procedures generally yielding favorable outcomes,4,5 the risk for functional, neurological, and sensory complications remains high.6,7 These risks may increase medicolegal exposure for physicians and institutions, contributing to neurosurgeons experiencing some of the highest rates of malpractice litigation among physicians in the United States.8
The distribution of spine procedures is not uniform, with extradural procedures, such as spine fusion and decompression, comprising an increasingly large share.3,9 Extradural procedures primarily address degenerative pathology such as disc herniation and spinal stenosis, typically in older patients, with outcomes centered on pain and functional improvement.3,10,11 In contrast, intradural procedures encompass neoplastic and congenital pathologies, including intramedullary tumors, tethered cord syndrome, and myelomeningocele, and require planned dural exposure and microsurgical dissection. These procedures carry distinct neurological and cerebrospinal fluid-related risks, with outcomes centered on neurological preservation and long-term functional status.12–17 Despite these differences, much of the limited medicolegal investigation within spine surgery has not stratified by procedure type, treating spine procedures as a singular entity.18,19
To address this gap in the literature, this study aimed to investigate malpractice litigation related to intradural spine procedures in the United States, identifying key trends and procedural risk patterns to inform future practice.
Methods
This retrospective study analyzed malpractice litigation related to some of the most common intradural spine procedures in the United States, specifically intramedullary mass resection, extramedullary mass resection, myelomeningocele repair, and tethered cord release. These procedures were selected because they represent common and clinically distinct intradural pathologies spanning both pediatric and adult populations, allowing for evaluation of medicolegal trends across varied indications and patient demographics.
The Westlaw legal database (Thomson Reuters, New York, NY) was selected due to its comprehensive repository of legal cases, including more than 40,000 entries from all 50 states, and its established use in medicolegal research. The Westlaw database only includes cases that were tried in court; therefore, cases that were settled outside of or prior to trial were not included. To identify relevant cases, a Boolean search was performed, using the terms (myelomeningocele OR tethered cord OR untethering OR detethering OR intramedullary OR extramedullary OR intradural) and (malpractice OR negligence OR liability OR standard of care). All queried cases were evaluated for inclusion under the following criteria: (1) one of the listed procedures was central to the litigation, (2) the procedure occurred prior to the date of filing, and (3) workers’ compensation and/or insurance companies were not cited as defendants.
Each case was manually reviewed using a standardized data extraction protocol to collect details regarding allegations, patient outcomes, and legal proceedings. Two reviewers independently reviewed all cases, and discrepancies regarding case inclusion or extracted variables were resolved through consensus with the senior author. For each case, demographic and legal data were recorded, including the date of surgery, date of revision surgery (if performed), defendant(s) named in the lawsuit, type of alleged negligence, damages incurred by the patient, final verdict, appeal status (if applicable), original case outcome, payout amounts (if applicable), and time elapsed from surgery to case resolution. Appeal cases were further analyzed to determine the original ruling and whether the appellate court upheld or overturned the decision. Malpractice claims frequently involve multiple allegations of damages; thus, a single case may be associated with more than 1 category of negligence or specific type of damage. Each trial’s geographic state within the United States was subsequently categorized into regions defined by the US Census Bureau.
Estimated annual litigation frequency was calculated descriptively for each procedure category and was not intended to represent a true national malpractice incidence rate. First, the average number of identified litigation cases per year was calculated by dividing the total number of identified cases for each procedure by the study period in years, defined as the interval from the year of the first identified case, 1981, through the final year of data collection, 2025.
Second, this annualized litigation frequency was compared with published estimates of procedural volume for each corresponding procedure type. Because no single national source reported procedural volume for all included intradural procedure categories, procedure-volume denominators were obtained from multiple published sources specific to each procedure. When sources reported total procedural volume over a multiyear interval, annual procedural volume was calculated by dividing the total reported procedural volume by the number of calendar years represented. The source, calendar window, reported procedural volume, and annual procedural volume used for each denominator are reported in Table 1.
Published procedural volume.
The estimated number of procedures per identified litigation case was calculated using the following formula:
Estimated procedures per identified litigation case = annual procedural volume/average number of identified litigation cases per year.
Statistical Analysis
Descriptive statistics were used to summarize case characteristics, allegations, and legal outcomes. Categorical variables are presented as frequencies and percentages. Continuous variables are reported as means with minimum and maximum values where applicable. All analyses were performed using IBM SPSS Statistics version 29.0.
Ethical Considerations
This study was exempt from Institutional Review Board (IRB) approval, as it utilized publicly available legal case data without direct patient involvement.
Results
A total of 417 legal cases were reviewed, of which 22 met the inclusion criteria, including 1 case involving 2 procedures, resulting in 23 total procedure occurrences. The included cases spanned from 1981 to 2022, with 59.1% occurring since 2010. The years 2011 and 2018 demonstrated the highest annual frequency, with 3 cases reported in each year (Figure 1). Tethered cord release accounted for the largest proportion of procedure occurrences, followed by intramedullary mass resection, myelomeningocele repair, and extramedullary mass resection.
Estimated annual litigation frequency of intradural spine procedure claims.
Among the included cases, 68.2% involved adult plaintiffs, 86.4% occurred in civilian settings, and 63.6% were appellate proceedings (Table 2). Geographically, cases were reported from 14 states, 1 US territory, and 1 federal jurisdiction, spanning all 4 US Census regions, with the highest frequencies observed in the Midwest and Northeast regions (Figure 2). Physicians were the most frequently named defendants, followed by healthcare institutions and governmental entities (Table 2).
Case filing by Census region.
Case characteristics, settings, and defendants.
Allegations varied across cases, with many involving multiple claims. Failure to inform or obtain informed consent and procedural error were the most frequently cited allegations, present in 63.6% and 50.0% of cases, respectively (Table 3). Time from surgery to case outcome was unavailable for cases still pending final judgment; among resolved cases, the mean duration from surgery to legal resolution was 70.2 months (Table 3). One case resulted in a plaintiff verdict, while the remaining cases resulted in defense verdicts or were ongoing at the time of analysis (Table 3).
Legal allegations and case outcomes.
The estimated annual litigation frequency across the procedures investigated was approximately 1 identified litigation proceeding per 3200 procedures. Intradural mass resection had the highest estimated frequency at approximately 1 identified litigation proceeding per 1200 procedures, followed by tethered cord release at approximately 1 identified litigation proceeding per 2950 procedures and myelomeningocele repair at approximately 1 identified litigation proceeding per 4600 procedures.20–22
Discussion
Spine surgery carries a substantial risk of malpractice litigation, yet prior medicolegal analyses have largely treated spine procedures as a single entity. Extradural and intradural operations differ fundamentally in indications, technical complexity, complication profiles, and patient expectations, suggesting that litigation risk may not be uniform across procedure types. The present study provides a focused analysis of malpractice claims related to common intradural spine procedures in the United States, identifying procedure-specific trends and risk factors with implications for surgical practice and risk mitigation.
More than half of the cases occurred after 2009, paralleling national trends toward increased malpractice filings.23 Appellate proceedings occurred in 63.6% of cases in our cohort, far exceeding the 10% to 20% appeal rates reported in general US civil litigation, although similar to those reported in pediatric neurosurgery.19,24 This may relate, in part, to the severity and permanence of neurologic injury alleged in many neurosurgical cases, which can increase the perceived stakes of litigation. Appellate representation in this cohort may also reflect case-selection bias within publicly available legal databases. This finding is best interpreted as a descriptive feature of the captured cases rather than evidence that intradural spine procedure claims are uniquely likely to undergo appeal.
Among intradural spine procedures, myelomeningocele repair and tethered cord release are predominantly pediatric operations reflecting congenital pathology, whereas intramedullary and intradural extramedullary tumor resections occur more frequently in adults.25–27 In the present cohort, approximately two-thirds of plaintiffs were adults, and intradural mass resection accounted for a higher estimated annual litigation frequency than tethered cord release or myelomeningocele repair. These differences may reflect several factors, including procedural volume, age distribution, underlying pathology, baseline neurological status, postoperative expectations, and differences in how patients or families perceive functional decline. Adult patients may have different baseline functional expectations and perceptions of postoperative decline, whereas parental or guardian perspectives may shape expectations and decision-making in pediatric litigation. The decision to pursue legal action is likely multifactorial, and larger datasets that account for procedure volume and patient demographics are needed before conclusions can be drawn.
Consistent with the importance of perceived outcomes, allegations related to informed consent were present in approximately two-thirds of cases. Informed consent in surgical practice is often limited by poor patient comprehension of risks, benefits, and alternatives, with studies demonstrating substantial deficits in recall and understanding.28,29 These issues may be mitigated by implementing more structured informed consent discussions and reinforcing realistic patient expectations at multiple perioperative time points. Notably, allegations related to informed consent were not reported within a 2025 study of pediatric neurosurgery claims.19 This may reflect differences in how negligence categories were defined and cases analyzed, with further work in this area necessary to clarify this discrepancy.
Failure to treat and related defensive medicine allegations remain some of the most commonly cited types of negligence within medical malpractice in recent years.30–32 Intradural procedures echo this trend, with both temporal distribution and allegation patterns in our cohort reflecting this broader phenomenon. In addition to these broadly observed malpractice trends, procedural error was alleged in approximately half of the cases, exceeding reported overall neurosurgical rates by 13 percentage points.31 Across medicine, operative and surgical errors account for roughly one-quarter of paid malpractice claims.33 This pattern may be consistent with the technical demands and narrow margin for error associated with intradural spine procedures, although the small cohort size limits comparisons across specialties or procedure groups. Individual physicians were the most frequently named defendants, suggesting that surgeon-level communication, documentation, technical decision-making, and postoperative management may remain important targets for risk-reduction strategies. This should not be interpreted as excluding institutional contributors, but rather as reflecting the defendant patterns observed in this legal dataset.
Institutions were frequently named alongside physicians, likely reflecting vicarious liability doctrines, systems-level factors such as supervision and credentialing, and the role of institutional indemnification. The observed plaintiff verdict rate and indemnity payment in our cohort were approximately 3- and 2-fold higher than national averages across all specialties, respectively.8 These findings should be interpreted with particular caution, as they are based on only 1 plaintiff verdict and 1 indemnity payment. Accordingly, the financial results are not reliable estimates of typical payout risk in intradural spine procedures. They instead illustrate that high-value awards can occur in individual cases involving these procedures. Because nontrial settlements are not captured in this dataset, the true medicolegal and financial burden cannot be determined from the present analysis. Larger studies incorporating settlements, claims databases, and procedure-volume denominators are needed to better estimate financial exposure.
Limitations
This study has several limitations. The relatively small cohort size limits the generalizability of our findings and constrains subgroup analyses. The limited number of plaintiff verdicts further restricts meaningful comparative financial assessment. In addition, because the Westlaw database contains only publicly available and reported legal cases, many malpractice claims resolved through confidential or pretrial settlement are not represented, likely resulting in an underestimation of overall medicolegal exposure and associated financial impact. Accordingly, the reported annualized frequencies reflect identified cases available in the Westlaw database rather than the true incidence of malpractice litigation. Finally, medicolegal databases rely on legal documentation prepared by nonmedical personnel, which may introduce variability or misclassification in the reporting of clinical details and alleged negligence.
Conclusion
Intradural spine procedures demonstrate a distinct medicolegal profile, characterized by high appeal rates, frequent informed consent and procedural error allegations, and the potential for substantial financial exposure. These findings underscore the importance of structured patient communication and technical precision in mitigating litigation risk. Broader datasets incorporating settled claims are needed to more fully characterize medicolegal exposure in this population.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
References
- 1.↵Patil PG, Turner DA, Pietrobon R. National trends in surgical procedures for degenerative cervical spine disease: 1990-2000. Neurosurgery. 2005;57(4):753–758.
- 2.↵Passias PG, Jalai CM, Worley N, et al. Adult spinal deformity: national trends in the presentation, treatment, and perioperative outcomes from 2003 to 2010. Spine Deform. 2017;5(5):342–350. 10.1016/j.jspd.2017.02.002
- 3.↵Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976). 2005;30(12):1441–1445. 10.1097/01.brs.0000166503.37969.8a
- 4.↵Ogihara S, Yamazaki T, Inanami H, et al. Risk factors for surgical site infection after lumbar laminectomy and/or discectomy for degenerative diseases in adults: a prospective multicenter surveillance study with registry of 4027 cases. PLoS One. 2018;13(10):e0205539. 10.1371/journal.pone.0205539
- 5.↵Rajjoub R, Ghaith AK, El-Hajj VG, et al. Comparative outcomes of awake spine surgery under spinal versus general anesthesia: a comprehensive systematic review and meta-analysis. Eur Spine J. 2024;33(3):985–1000. 10.1007/s00586-023-08071-y
- 6.↵Bydon M, Abt NB, De la Garza-Ramos R, et al. Impact of resident participation on morbidity and mortality in neurosurgical procedures: an analysis of 16,098 patients. J Neurosurg. 2015;122(4):955–961. 10.3171/2014.11.JNS14890
- 7.↵Safaee MM, Lyon R, Barbaro NM, et al. Neurological outcomes and surgical complications in 221 spinal nerve sheath tumors. J Neurosurg Spine. 2017;26(1):103–111. 10.3171/2016.5.SPINE15974
- 8.↵Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice risk according to physician specialty. N Engl J Med. 2011;365(7):629–636. 10.1056/NEJMsa1012370
- 9.↵Bernstein DN, Brodell D, Li Y, Rubery PT, Mesfin A. Impact of the economic downturn on elective lumbar spine surgery in the United States: a national trend analysis, 2003 to 2013. Global Spine J. 2017;7(3):213–219. 10.1177/2192568217694151
- 10.↵Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296(20):2441–2450. 10.1001/jama.296.20.2441
- 11.↵Wei F-L, Zhou C-P, Liu R, et al. Management for lumbar spinal stenosis: a network meta-analysis and systematic review. Int J Surg. 2021;85:19–28. 10.1016/j.ijsu.2020.11.014
- 12.↵Chamberlain MC, Tredway TL. Adult primary intradural spinal cord tumors: a review. Curr Neurol Neurosci Rep. 2011;11(3):320–328. 10.1007/s11910-011-0190-2
- 13.↵Klekamp J. Spinal ependymomas. Part 1: intramedullary ependymomas. Neurosurg Focus. 2015;39(2):E6. 10.3171/2015.5.FOCUS15161
- 14.↵Umebayashi D, Naito K, Kurokawa R, et al. Epidemiology and comparative analysis of outcomes of intramedullary spinal cord tumor between pediatric and adult patients. Spine (Phila Pa 1976). 2024;49(2):107–115. 10.1097/BRS.0000000000004775
- 15.↵Kobets AJ, Oliver J, Cohen A, Jallo GI, Groves ML. Split cord malformation and tethered cord syndrome: case series with long-term follow-up and literature review. Childs Nerv Syst. 2021;37(4):1301–1306. 10.1007/s00381-020-04978-9
- 16.↵Alexander MA, Steg NL. Myelomeningocele: comprehensive treatment. Arch Phys Med Rehabil. 1989;70(8):637–641.
- 17.↵Bowman RM, Mohan A, Ito J, Seibly JM, McLone DG. Tethered cord release: a long-term study in 114 patients. J Neurosurg Pediatr. 2009;3(3):181–187. 10.3171/2008.12.PEDS0874
- 18.↵Ibrahim MT, Banatwala U, Albert G, et al. Medical malpractice litigation in spine surgery: a systematic review. JBJS Rev. 2025;13(8):e25.00071. 10.2106/JBJS.RVW.25.00071
- 19.↵Koutsouras GW, Blomfield AK, Mazzola C. Pediatrics neurosurgical malpractice claims: a 43-year review of legal databases. J Neurosurg Pediatr. 2025;37(2):99–105. 10.3171/2025.5.PEDS2575
- 20.↵Liu H, Duan L, Li Z, Liu Y, Wang Y. Incidence and survival of patients with malignant primary spinal cord tumors: a population-based analysis. Neurospine. 2024;21(2):588–595. 10.14245/ns.2347300.650
- 21.↵Bhimani AD, Selner AN, Patel JB, et al. Pediatric tethered cord release: an epidemiological and postoperative complication analysis. J Spine Surg. 2019;5(3):337–350. 10.21037/jss.2019.09.02
- 22.↵Shao B, Chen J-S, Kozel OA, et al. Postnatal myelomeningocele repair in the United States: rates and disparities before and after the management of myelomeningocele study trial. Neurosurgery. 2023;93(6):1374–1382. 10.1227/neu.0000000000002604
- 23.↵Courts NCfS. State Court Caseload Statistics. National Center for State Courts. https://www.courtstatistics.org/other-pages/statecourtcaseloadstatistics?utm. 16 April 2025.
- 24.↵Eisenberg T. Appeal rates and outcomes in tried and nontried cases: further exploration of anti‐plaintiff appellate outcomes. J Empirical Legal Studies. 2004;1(3):659–688. 10.1111/j.1740-1461.2004.00019.x
- 25.↵Arnautovic K, Arnautovic A. Extramedullary intradural spinal tumors: a review of modern diagnostic and treatment options and a report of a series. Bosn J Basic Med Sci. 2009;9 Suppl 1(Suppl 1):S40–S45. 10.17305/bjbms.2009.2755
- 26.↵Gausper A, Miller A, Wright W, et al. Adults are not just big kids: adults have higher reoperation and complication rates following lumbar laminectomy for tethered cord release. J Clin Neurosci. 2025;142:111664. 10.1016/j.jocn.2025.111664
- 27.↵Karsonovich T, Alruwaili AA. Myelomeningocele. StatPearls. StatPearls Publishing; 2025.
- 28.↵Kinnersley P, Phillips K, Savage K, et al. Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. Cochrane Database Syst Rev. 2013;2013(7):CD009445. 10.1002/14651858.CD009445.pub2
- 29.↵Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274–286. 10.1001/jamainternmed.2014.6016
- 30.↵Miziara ID, Miziara CSMG. Medical errors, medical negligence and defensive medicine: a narrative review. Clinics (Sao Paulo). 2022;77:100053. 10.1016/j.clinsp.2022.100053
- 31.↵Iqbal J, Shafique MA, Mustafa MS, et al. Neurosurgical malpractice litigation: a systematic review and meta-analysis. World Neurosurg. 2024;188:55–67. 10.1016/j.wneu.2024.04.112
- 32.↵Sharma A, Whitlock KG, Gage MJ, Lassiter TE, Anakwenze OA, Klifto CS. Malpractice trends in shoulder and elbow surgery. J Shoulder Elbow Surg. 2021;30(9):2007–2013. 10.1016/j.jse.2020.12.018
- 33.↵Schaffer AC, Jena AB, Seabury SA, Singh H, Chalasani V, Kachalia A. Rates and characteristics of paid malpractice claims among US physicians by specialty, 1992-2014. JAMA Intern Med. 2017;177(5):710–718. 10.1001/jamainternmed.2017.0311
