Back

Checking the Records for Complications after Spine Surgery

In a perfect world, your entire medical history would be accurately described in your medical records. But how reliable are doctors' medical records? You may not care if your records are 100 percent complete. But much medical research relies on doctors' records. That means those records are used to understand important medical issues. This makes accuracy very important.

These authors wanted to see how accurate surgeon's records are. They looked at the records for 166 patients who had cervical spine surgery. The authors wanted to see if post-surgery problems with talking and swallowing were reported equally by surgeons and patients. Records were studied from appointments six weeks, three months, and six months after surgery. The records were then compared to a survey given to patients.

Surgeons' records reported far fewer problems than the patients did. The records showed that only 11 percent of patients had problems swallowing, and only five percent of patients had problems talking. The patient surveys showed that 57 percent of patients had problems swallowing, and 30 percent had problems talking. The results didn't match well for any surgeon. Mild and moderate problems were most often missing in the medical records. But even severe problems went unreported.

This is not very good news for medical researchers. It is impossible to tell if these results are also true for other types of surgery. And this study had some limitations. But it certainly makes a case that surgeons' records may not be the best way to get a true picture of complications after surgery.

The authors suggest the lack of accuracy may be why different outcome studies can get such different results. They recommend that patient reports should be included in any study of outcomes after surgery.

References: Charles C. Edwards II, MD, et al. Accurate Identification of Adverse Outcomes after Cervical Spine Surgery. In The Journal of Bone and Joint Surgery. February 2004. Vol. 86-A. No. 2. Pp. 251-256.

Back