Improper performance of pain management procedure

By Olga Maystruk, Designer and Brand Strategist

Presentation

On April 14, a 50-year-old man with a long history of chronic pain, spinal injuries and procedures, depression, and obesity, came to see Anesthesiologist A for pain management. The patient sought treatment for radiating neck and low back pain and migraine headaches. The patient’s medications included methadone, ibuprofen, paroxetine, tizanidine, and hydrocodone/acetaminophen (7.5/325). 

An MRI of the patient’s lumbar spine revealed degenerative disc disease at the L3-4 and L4-5 vertebrae with spinal stenosis at L4-5. A cervical spine MRI showed a C4-5 fusion but was otherwise normal. 

Physician action

On April 22, Anesthesiologist A performed a bilateral L4-5 epidural steroid injection (ESI). The patient did not return for a follow-up appointment one month later. 

However, the patient did return to the physician’s office on July 1. He reported mild pain relief for approximately ten days following the ESI. The patient’s motor strength was normal, 5/5 throughout.

Three weeks later during the next follow-up appointment, Anesthesiologist A and the patient discussed an epiduroscopy and Percutaneous Ablation and Curettage and Inferior Foraminotomy (PACIF) with a plan to refer to neurosurgery if the patient saw no relief. The patient agreed to the procedures.

On August 16, the patient was admitted for the epiduroscopy and PACIF at L5 on the right side. During the procedure, Anesthesiologist A encountered epidural space adhesions and could not obtain access to the neural foramen of L4-5 on the right. Due to minor but persistent bleeding, Anesthesiologist A decided to terminate the procedure and injected 5 ml of a hemostatic matrix in the area of bleeding and retracted the scope.

A neurosurgery consultation was obtained. Neurosurgeon A noted no neurological deficits on examination and indicated no need for neurosurgical intervention. 

Anesthesiologist A saw the patient the next day and noted weakness of the right leg. An MRI showed postoperative changes at L4-5 with an epidural collection resulting in mild stenosis starting at L4-5 and extending to S2, consistent with evolving traumatic epidural hemorrhage. The patient was discharged to home.

On August 21 during a follow-up telephone call, the patient reported inability to raise his big toe and foot on the right side. Anesthesiologist A referred the patient to Neurosurgeon B.

Neurosurgeon B performed electromyography and nerve conduction velocity tests on August 26. The patient had significant pain and weakness and expressed concern for injury in the past 10 days. 

The next day, the patient underwent decompression and laminectomy of L4-5 and L5-S1 with removal of the hemostatic matrix and an epidural hematoma. The patient was discharged the next day with an ankle foot orthotic.

Following physical therapy, the patient’s foot drop resolved; however, there may be elements of secondary gain in the future.

Allegations

The patient filed a lawsuit against the anesthesiologist alleging:

• performing a non-medically indicated and experimental procedure;
• improper performance of the procedure; and
• failure to obtain timely neurosurgical consultation.

Legal implications

While acknowledging common complications during surgery such as bleeding, experts for the defense expressed concern about the follow-up care. Additionally, one consultant was critical of the PACIF procedure itself due to it still being under development at the time. In this expert’s opinion, the choice of the procedure and injection of a hemostatic matrix made the treatment in this case fall below the standard of care. 
Expert consultants for the defense did not note any issues with the timing of the neurosurgical consultation.

Disposition

The case was settled on behalf of the anesthesiologist.

More on improper performance.
Risk management for anesthesiologists.