On 11/13/2010, a 64-year-old male with a past medical history significant for hypertension, diabetes, hyperlipidemia, renal failure, status post-renal transplant, and coronary artery disease suffered a fall secondary to feeling dizzy and unsteady. The patient fell on his left leg with subsequent development of low back pain and radicular pain as well as left leg weakness. In early April 2011, the patient suffered another fall with worsening symptoms of low back pain and radiating left leg pain. Thoracic and lumbar spine x-rays revealed a new T12 compression fracture. The MRI scan of the lumbar spine showed a T12 compression fracture with retropulsion of the posterior superior margin of the T12 vertebral body into the spinal cord. Electrodiagnostic studies revealed a left femoral neuropathy superimposed upon a diabetic neuropathy.
A neurosurgeon saw the patient on 4/8/2011. The patient continued to have intractable pain in his back, was unable to sit up, and was wheelchair bound. The neurosurgeon recommended a T12 kyphoplasty. On 4/25/2011, the neurosurgeon took the patient to surgery for a T12 kyphoplasty. The surgical procedure was complicated by extravasation of cement into the spinal canal, which resulted in spinal cord compression. The patient was noted to be paraplegic following the kyphoplasty procedure, and the neurosurgeon urgently returned the patient to surgery, where she performed a T10-T12 laminectomy with removal of the extravasated cement from the previous kyphoplasty procedure. A puncture in the dural tube was also noted on the right, which was sutured. Postoperatively, the patient failed to make any neurological recovery. The patient remained paraplegic with loss of bowel and bladder function. On 5/10/2011, the patient was transferred from the hospital to an acute rehabilitation facility.
The standard of care in performing kyphoplasty requires visualization of the Jamshidi needles in both the AP (anteroposterior) and lateral views under fluoroscopy. This is usually completed on multiple occasions with gradual placement and movement of the needle to the vertebral body through the vertebral pedicle.
On 10/11/2011, the neurosurgeon was interviewed by a Medical Board investigator and District Medical Consultant regarding her care and treatment of the patient. The neurosurgeon reported at the interview that during the patient’s kyphoplasty procedure, she placed the needle in the left pedicle first and that it looked to be in good position. In the hope of reducing the amount of radiation exposure to the patient, the neurosurgeon stated that she departed from her normal procedure of checking both the AP and lateral views and proceeded with visualizing the needle placement only in the lateral view. This breach in the surgical technique is associated with the subsequent complication of extravasation of the cement to the canal.
The Medical Board of California judged that the neurosurgeon committed gross negligence in her care and treatment of the patient given that she failed to visualize the Jamshidi needle placement in both the AP and lateral planes during performance of the kyphoplasty procedure on the patient.
The Medical Board of California issued a public reprimand.
Date: December 2014
Medical Error: Procedural error
Significant Outcome: Permanent Loss Of Functional Status Or Organ
Case Rating: 3
Link to Original Case File: Download PDF
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