The Verdict Is In

Claim: Anesthesiologist Accidentally Injected Into the Patient's Spinal Cord During a Paraspinal Block and Improperly Discharged the Patient Home Despite Significant Neurologic Deficits

By – Kat Todd, Esq

The patient was a 57 year old female with a history of low grade follicular lymphoma as well as depression, obesity and hypertension. She had developed enlarged lymph nodes, and there was a concern for transformation of the previously low grade lymphoma. Accordingly, on December 7th, she presented to the Hospital to undergo deep right axillary lymph node excision.

The patient was first examined pre-operatively by the surgeon. The patient was then interviewed and examined by the anesthesiologist. The anesthesiologist noted the patient was 5'3 and weighed 216 lbs. Her vital signs were within normal limits, including a blood pressure of 118/72 and pulse of 57. He assessed her to be ASA Class 2.

The anesthesiologist discussed anesthesia options with the patient. Specifically, he discussed the option of general anesthesia with inhalation agents as well as a regional technique consisting of a paravertebral block. A paravertebral block would provide prolonged postoperative pain control with decreased nausea and vomiting. In addition, it would decrease the chance of chronic postoperative pain, would allow the patient to avoid the risks of general anesthesia and is thought to preserve the integrity of the immune system. Ultimately, the patient provided informed consent to a paravertebral block in the thoracic spine after being advised the risks of the block included nerve injury, vascular injury, spinal cord injury and/or a lung injury.

The patient was administered some IV sedation and positioned in the left lateral decubitus position. The anesthesiologist then felt for the spinous process at each thoracic level he intended to inject (T1 through T4). He measured laterally 2.5 cm and marked each location. He then placed each needle separately in a perpendicular fashion to the skin in the sagittal plane. He located the transverse process. He walked the needle off either the inferior or superior edge of the transverse process by one additional centimeter. He ensured there was no medial angulation of the needle when he injected fentanyl and midazolam. He also administered propofol for deep sedation. Overall, the block appeared to go without complication.

The surgeon performed the lymph node excision and placed a drain. The patient was then transferred awake and in stable condition to the PACU. Shortly after her transfer to the PACU, the patient complained of numbness of her right arm and right leg as well as an inability to move either extremity. She denied any shortness of breath or dyspnea. The anesthesiologist was notified and directed continued monitoring. Less than 30 minutes later, the patient reported sensation was returning to her right sided extremities. She regained full motion of her right lower extremity shortly thereafter. Within two hours, the patient reported both upper and lower extremities had regained normal function and sensation.

However, whilst still in the PACU, she then reported non-radiating pain to the left side of her chest. The anesthesiologist ordered a chest x-ray. The chest x-ray was read as within normal limits. The patient eventually reported full resolution of all post-operative complaints. When she met discharge criteria, the anesthesiologist approved her transfer to the Step-Down Unit (SDU) for additional monitoring. When she could ambulate and dress independently, she was discharged from the Hospital into her husband's care.

Dispute As to the Patient's Condition At Discharge

The patient and her husband testified that she continued to have significant neurologic deficits at the time of discharge. Specifically, she testified that she had complete paraesthesia and paraplegia from her right shoulder to her right foot at the time of discharge. Additionally, she testified that she had a right eye droop. Her husband corroborated her testimony. Conversely, the involved PACU and SDU nurses, as well as the anesthesiologist, testified the patient's complaints of numbness and pain had fully resolved before she was discharged home. The surgeon testified that she was unaware the patient had any unusual complaints in the PACU. It was undisputed that the patient's neurologic deficits did return once she arrived home from the Hospital.

Communications Following Discharge

The evening following the procedure, the patient contacted the surgeon to report continued difficulties. The surgeon contacted the anesthesiologist who then called the patient. The anesthesiologist initially advised the patient that her complaints were likely due to the block which would eventually wear off. When the patient reported continued neurologic deficits 48 hours later, the anesthesiologist facilitated the performance of an MRI of the spine. The imaging revealed severe cervical stenosis as well as swelling at T2. The patient was diagnosed with probable ischemic myelopathy as well as Horner's Syndrome.

Differing Expert Opinions On Causation

Plaintiff's anesthesiology expert testified that this injury could not have occurred in the absence of a breach of the standard of care. Further, the plaintiff's expert opined the anesthesiologist must have inadvertently injected into the spinal cord, either due to malpositioning of the spine or malpositioning of the needle, despite his stated precautions.

The plaintiff's neurosurgery expert opined the injury was caused by direct needle trauma to the spinal cord, even though there was no evidence of penetrating needle trauma, any needle tract nor any bleeding on the MRI taken four days after the block. Conversely, the defense anesthesiology expert opined that the block was indicated and was performed at all times in accordance with the standard of care. The defense neurosurgery and neuroradiology experts both opined the plaintiff suffered a spinal cord infarct, likely due to necessary intraoperative positioning of the neck and (previously undiagnosed) severe cervical stenosis which interrupted the vascular supply to the spinal cord during the procedure. Further, all treating physicians testified that they believed the patient had suffered a rare spinal cord infarct; no treating physicians believed the anesthesiologist had inadvertently penetrated the spinal cord during the performance of the block.

All experts agreed that no act nor omission following performance of the block caused plaintiff any injury. Earlier diagnosis and admission to the Hospital would not have improved her outcome as there would be no intervention for either direct spinal cord trauma nor a spinal cord infarct.

Survey Questions

The patient and her husband pursued the case in State Court. The anesthesiologist and the Hospital were named defendants. Ultimately, the plaintiffs dismissed the Hospital from the litigation.

1. Do you believe the patient's adverse medical outcome was preventable?

  1. Yes
  2. No

2. Do you believe the defense experts' opinions affected the jury's deliberations?

  1. Yes
  2. No

3. The case proceeded to trial against the anesthesiologist. How do you guess the case was resolved?

  1. The jury found in favor of the anesthesiologist.
  2. The jury found in favor of the plaintiff.

To answer these questions, click here. By participating, you could win $150 for you and an additional $150 for your site.

The Previous "Verdict Is In"

The results of the July 2016 installment of "The Verdict Is In" are as follows:

  1. 1. In your opinion, should there have been discussion with subsequent documentation about the patient's use of alcohol by the ED-1 care team?
     
    84.72% Yes
     
    15.28% No
  2. 2. In your opinion should PA-1 and/or EP-1 have identified that the patient was intoxicated?
     
    83.33% Yes
     
    16.67% No
  3. 3. In your opinion did the patient's cardiorespiratory event result from:
     
    34.72% Prolonged QT leading to Torsades.
     
    65.28% Opiate drug-induced respiratory depression.
  4. 4. PA-1, EP-1, EP-2, Hospital-1, Hospital-2, Ambulance Company and the ED Group were named as defendants. How do you guess the case was resolved?
     
    26.39% All defendants were dismissed.
     
    73.61% PA-1, EP-1 and the Ambulance Company settled; all other defendants were dismissed.

Who Won the Survey Raffle?

The winner of the raffle for the above case was Chris Burke, MD. He practices at Natividad Medical Center, Salinas, CA. Dr. Burke receives a debit card worth $150; his site also receives a debit card worth $150, which can be used for any worthy cause.