On 03/22/2007, a patient suffered a back injury while making a jump on a snow machine. She did not seek medical attention given lack of insurance. The pain subsided, and she was able to work again. She changed jobs and became a unit secretary at a hospital after realizing that she would need medical insurance.
In August 2007, her pain increased, and she was seen at the emergency department, where she was diagnosed with T10 and T11 spinal compression fractures.
On 11/08/2007, the patient met with a neurosurgeon for an evaluation. Options were discussed, including kyphoplasty, a procedure which uses medical grade cement (methyl methacrylate). An MRI was scheduled for 11/27/2007. She was referred to a sports medicine physician for nonsurgical treatment.
On 12/27/2007, the patient met again with the neurosurgeon to discuss her options. She decided to undergo kyphoplasty.
On 01/04/2008, the neurosurgeon performed the kyphoplasty procedure. He first worked on the T11 level.
A kyphoplasty procedure requires inserting balloons into the vertebrae and expanding them to create a space for cement. In placing one of the balloons, he penetrated the front of the vertebral body. He used a technique to plug the hole. Then, there was a balloon rupture within the vertebral body, with a little leakage of fluid and contrast through the anterior wall of the body. Some of the cement filling leaked through the anterior wall. The leakage was considered to be a benign event as described by the Administrative Law Judge (ALJ) reviewing the case.
There were no significant complications. He then worked on the T10 level. The initial needle pass from the left side was too far medial and extended too far to the rear, and it passed through the spinal canal. This channel was developed to the point of having a working cannula in it before the neurosurgeon realized it was in the wrong location. He did not realize, however, that he had breached the spinal canal. He withdrew and developed a new channel in the correct location.
After balloon inflations in the T10 vertebral body, the neurosurgeon began to inject cement. Less than thirty seconds after the neurosurgeon began injecting on the left side at T10, the fluoroscopic images showed extravasation of dark material traveling in a smooth-sided vertical channel upward and downward from T10. The neurosurgeon apparently did not notice this finding.
The neurosurgeon continued to inject cement while the vertical shadow became more and more pronounced. After a minute and forty seconds, on review, the shadow could be clearly seen extending all the way past the T9 level and into the T8 level. Injection continued for another minute so that the period of injection after the leakage first became visible was at least two minutes and forty seconds. During the early part of this period, there was some contrast circulating in the imagery, which was traced to a pain injection.
The ALJ explained that one could surmise from the images that the leakage was either anterior or posterior to the vertebral body based on the A/P images alone, but the lateral images (which were not available given a limit in how many images could be saved) would have indicated that the leakage was most likely posterior to the vertebral body. A posterior leakage has the potential to infect pressure or heat damage on the spinal cord.
During testimony, the neurosurgeon recalled being puzzled by the images as he completed the kyphoplasty, but apparently did not appreciate the gravity of the situation. It was noted that the batch of methyl methacrylate used in the procedure was recalled given that it was too slow to cure to the right viscosity, although the surgeon is supposed to test the cement before injection to confirm it has reached the correct viscosity.
The neurosurgeon then injected pain relief medications around T10. He dictated an operative report and noted no complications.
Following the procedure, the patient was transferred to the Post Anesthesia Care Unit (PACU). After awakening, she was found to have bilateral weakness of her legs. A CT scan later showed compression of the spinal cord due to the cement that had leaked into the spinal canal.
The patient was taken back to the operating room, where the neurosurgeon performed an emergency laminectomy to remove the cement. The cement had been in the canal for two and a half hours. The amount of cement in the canal was considered “tremendous.”
During the second surgery, the patient continued to suffer a dense left paraplegia and right paraplegia, which failed to resolve. A post-operative CT scan revealed residual methyl methacrylate that had not been removed during the second surgery.
The patient required intensive rehabilitation with physical and occupational therapy after the operations. She was discharged on 02/12/2008.
The patient continued to suffer neurological deficits after the hospitalization. She underwent two subsequent surgical procedures and was left with permanent, irreversible injuries, including lower extremity weakness and bladder and bowel dysfunction.
The Board judged the neurosurgeon’s conduct to be considered professional incompetence, gross negligence, or repeated negligent conduct.
The neurosurgeon underwent an extensive investigation by the Board given concern over his conduct. His license was restricted in that he was ordered not to conduct surgery in which operative instruments are visualized by fluoroscopy unless he does so in the presence of a licensed surgeon or radiologist.
Date: December 2010
Symptom: Back Pain
Medical Error: Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 4
Link to Original Case File: Download PDF
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