Failure to properly administer an epidural steroid injection

by Olga Maystruk, Designer and Brand Strategist, and 
Karen Werth, MBA, CPHRM, Lead Risk Management Representative

Presentation and physician action

‍On June 15, a 32-year-old man visited his primary care physician with reports of neck and upper back pain radiating to the left arm. These symptoms emerged after a motor vehicle accident four years earlier. The patient had a history of anxiety, depression, insomnia, migraines, tremors, and hives. His medications included duloxetine, levocetirizine, lorazepam, montelukast, and zolpidem.

X-rays of the patient’s cervical spine demonstrated flatback syndrome, moderate degenerative disc disease at C5-C6, and mild spondylosis. He was referred to a rheumatologist.

On September 10, the patient came to a rheumatology clinic with reports of hand, elbow, shoulder, and intermittent neck pain with left arm neuropathy and significant radiculopathy causing headaches. The rheumatologist ordered an X-ray, ultrasound of both hands, and various laboratory work. The ultrasound revealed mild active non-destructive inflammatory arthritis. The physician prescribed gabapentin and referred the patient to a pain management specialist.

Two days later, the patient was seen by a pain management specialist. After reviewing results from the cervical spine X-ray, the physician’s diagnosis included cervicalgia, cervical region radiculopathy, cervical spondylosis, and cervical muscle spasms. The pain management specialist performed a left C6-7 cervical epidural steroid injection (ESI) and recommended physical therapy, therapeutic exercises, transcutaneous electrical nerve stimulation, and strengthening.

On October 14, the patient returned to the pain management specialist with reports of cervical spine pain radiating to the upper right arm as well as stiffness, numbness, and tingling. The patient reported his symptoms had improved by 30 percent after the ESI in September. The pain management specialist recommended a cervical MRI without contrast and physical therapy.

Before those recommendations were fulfilled, the pain management specialist performed a second left C6-7 cervical ESI. The procedure was noted in the records to have gone well with no adverse effects. However, the patient reported to subsequent treating physicians that he had involuntary movement (“jerking” of the left arm) and severe stabbing pain during the procedure.

On November 3, the patient underwent a cervical spine MRI which revealed a multi-level uncovertebral joint hypertrophy with disc protrusions on the left side at C5-C6 and C6-C7, and a syrinx at C6-C7.

The patient continued to experience pain, numbness, and limited use of his left arm.

Allegations

‍A lawsuit was filed against the pain management specialist alleging failure to:

• perform a thorough evaluation before performing two ESI procedures; 
• properly perform the ESI resulting in a spinal cord injury; 
• provide proper pain management care and treatment; and
• address patient’s concerns during and after the ESI procedure. 

Legal implications

‍According to consultants for the plaintiff, the pain management specialist did not meet the standard of care by failing to obtain a cervical MRI before administering the ESIs and opposing fluoroscopic X-rays during the procedures.  Consultants for the defense echoed the concerns about lack of imaging.

Documentation for the second ESI presented an additional issue for the defense. The notes for both procedures appeared identical, which suggested a lack of attention to the procedure and documentation.

Disposition

‍This case was settled on behalf of the pain management specialist.

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‍More on improper performance.

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