Found 20 Results Sorted by Case Date
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California – Internal Medicine – Missed Diagnosis With Repeated Visits For Wheezing, Extremity Swelling, And Uncontrolled Type 2 Diabetes



On 4/12/2010, a 60-year-old male complained of wheezing and had a history of Type 2 diabetes.  An internist obtained a sparse history, consisting of four sentences, even though the internist had not previously known the patient.  The internist stated that the patient complained of “asthma” and had been non-compliant with diet, exercises, and medications required for control of his Type 2 diabetes.  The internist did not obtain or document a history of present illness regarding the wheezing, asthma, or diabetes. Some vital signs were obtained, but an abnormal pulse of 120 bpm was not commented upon by the internist, and a respiratory rate was not obtained.  A review of symptoms was documented and reported to be normal, but its accuracy was uncertain given the internist’s use of an electronic template. Despite the absence of wheezing in the documented examination, and even though the internist did not perform a standard workup for asthma, the internist prescribed a burst course of a systemic corticosteroid and inhaler to the patient.  The internist did not perform and/or did not document a cardiorespiratory physical examination of the patient. He ordered a series of laboratory tests to assess the patient’s Type 2 diabetes, and the patient was given home instructions, but these related to Type 1 rather than Type 2 diabetes. On the following day, the internist did request that staff contact the patient regarding a nutrition course for diabetics.

On 4/25/2010, the patient was seen by another physician for complaints of swelling to his left foot.  The patient reported that the swelling had started 2 days previously, was not the results of trauma, and did not prevent him from walking.  Physical examination revealed swelling over the dorsal foot. The plan was for the patient to follow up with his primary care physician, the internist.

On 4/27/2010, the patient had a telephone encounter with the internist regarding the patient’s edema.  The patient was advised to have laboratory tests performed and scheduled an appointment the following week.  The patient complied with the request, and the test results included glucosuria, normal hemoglobin and WBC count, an estimated glomerular filtration rate of 57, Hemoglobin A1c of 13.6, albumin of 3.2, and urinary protein/creatinine ratio of 0.57.  These were documented in the patient’s chart on 4/28/2010, but there was no documentation that any physician reviewed the results on that date.

On 5/2/2010, the patient sent an email to another physician in which he stated that he had not been contacted after his last telephone encounter with the internist and that he was concerned about the swelling in his feet and legs, which he stated had been ongoing since 4/22/2010.  The patient was instructed to make an appointment with the internist when he returned on 5/3/2010.

On 5/10/2010, the patient was seen by the internist.  A brief history was recorded, which stated the patient’s concerns about the swelling of his lower extremities and the patient’s uncontrolled diabetes due to his non-compliance with diet and exercise.  The patient apparently also complained of a cough, which was only referenced in the assessment and plan, and which the internist attributed to a medication the patient had been prescribed for hypertension.  Again, some vital signs were recorded, and the patient was noted to have a rapid heart rate (110 bpm), but this was not commented upon. Neither respiratory rate nor SpO2 was recorded at this visit. An incomplete cardiovascular and pulmonary examination was reported as normal, despite the patient’s tachycardia.  A jugular venous distention examination was not performed. The internist’s assessment included diabetic nephropathy (kidney disease or damage caused by diabetes). He ordered tests, including a 24-hour urine protein and albumin tests. At the same visit, however, he prescribed both metformin (an antidiabetic drug that is contraindicated in patients with renal insufficiency) and Lasix.

On 5/16/2010, the patient contacted the advice nurse and reported that he was having difficulty sleeping.  On 5/17/2010, the patient’s wife emailed the internist and stated that the patient “still has a horrible hacking cough which doesn’t [sic] allow him to sleep much…his legs and feet are still swollen…”  Th internist advised the patient to make an appointment to return to see him regarding these problems.

On 5/25/2010, the patient had his third face-to-face encounter with the internist.  A chief complaint was not listed. The subjective portion of the examination was brief and cursory.  It stated that the patient’s blood sugars had been testing in the mid-200’s and that the edema of the legs continued despite taking a daily dose of Lasix.  The patient’s heart rate was again elevated, this time at 108 bpm, but the internist neither commented on the patient’s persistent tachycardia nor did he document a heart examination that included listening for a third sound.  The patient’s cough was again briefly noted, and this was attributed to his being “apparently allergic” without any documented examination of the throat or nose. Although the internist continued to believe that the edema was related to renal insufficiency, he also continued the patient on metformin 500 mg BID, which was contraindicated as mentioned above.  Although a differential diagnosis was not charted, the internist did order an EKG and a chest x-ray for what he later described as cardiac concerns. However, the tests were not ordered urgently, and the more appropriate procedure, an echocardiogram, was not ordered at that time. The internist placed the patient on disability for one month.

On 5/28/2010, the patient underwent the chest x-ray, which was interpreted as showing an enlarged heart and pleural edema consistent with congestive heart failure, but this was not reported until 6/8/2010.  On 6/1/2010, the patient sent the internist an email in which he stated that he had not had any real improvement in the swelling of his feet and legs despite an increased dose of Lasix, compression stockings, and a low sodium diet.  The internist replied: “I will see you soon. I might need to refer you to nephrology.”

The patient returned on 6/3/2010, at which time his recorded vital signs were significant for low blood pressure (96/89) and an elevated pulse (103).  The chief complaint was stated to be edema, but the history was limited to a brief comment that “…persists with edema. It is less today.” Although, as set forth above, the internist had ordered a chest x-ray, he did not follow up to find out the results of that exam during this patient encounter.  The examination was reported to be the same as the exam on 5/25/2010, likely as the result of the use of an electronic template. The internist’s impression was peripheral edema “probably due to hypoalbuminemia but will check for other possibilities.” The internist ordered multiple diagnostic tests, including a renal ultrasound.

On 6/8/2010, the renal ultrasound was reported as showing pleural effusion and ascites.  The previously ordered x-ray, as stated above, was read as showing congestive heart failure.  The internist contacted the patient and advised that the x-ray showed changes that suggested heart failure.  The internist asked the patient to have the EKG done and to come in for examination the following day. An electrocardiogram was also ordered but was not scheduled until 6/23/2010.  On 6/9/2010, the patient suffered a cardiac arrest and was taken to another facility. He was found to have anoxic brain injury and died on 6/15/2010.

The Medical Board of California judged that the internist’s conduct departed from the standard of care because he failed to obtain a complete history, appropriately work-up the patient for a diagnosis of asthma, perform an adequate physical examination for possible causes of the patient’s complaints at each of the four encounters, recognize signs and symptoms of congestive heart failure, formulate an appropriate differential diagnosis, and respond emergently to a patient in a decompensated clinical state.  The internist also inappropriately prescribed a corticosteroid and an antidiabetic drug and persevered in consideration of remote diagnoses and unreasonably delayed in considering likely causes of the patient’s cough, wheezing, tachycardia, hypotension, and edema.

The Medical Board of California placed the internist on probation for 5 years and ordered the internist to complete a medical record keeping course, an education program (at least 40 hours per year for each year of probation) and a clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine and be assigned a practice monitor.  The internist was prohibited from supervising physician assistants.

State: California


Date: May 2015


Specialty: Internal Medicine


Symptom: Shortness of Breath, Cough, Swelling


Diagnosis: Heart Failure, Diabetes


Medical Error: Failure to order appropriate diagnostic test, Delay in diagnosis, Failure to examine or evaluate patient properly, Failure to follow up, Improper medication management, Lack of proper documentation


Significant Outcome: Death


Case Rating: 5


Link to Original Case File: Download PDF



California – Neurosurgery – Three Lumbar Discogram And Discectomy Procedures After Steroid Injections Fail To Improve Symptoms



On 10/6/2006, a 51-year-old male presented to a neurosurgeon with complaints of low back and buttock pain with occasional tingling of the left leg.  The neurosurgeon examined the patient and noted paralumbar tenderness, muscle spasm, decreased range of motion of the left leg, and decreased sensation in the left groin, left upper thigh, left foot, and left ankle.  The neurosurgeon recommended x-rays of appropriate areas, MRI scans of the lumbar spine with and without weight bearing, a CT scan of the cervical spine, an EMG study of the left arm and leg, and a nerve conduction study of the left ulnar nerve.  The patient underwent these diagnostic tests the same day.  The neurosurgeon interpreted the diagnostic tests: from the EMG, a left L4, L5, and S1 radiculopathy, left C6 and C7 radiculopathy, and ruled out left ulnar neuropathy; from the weight-bearing MRI, an L5-S1 6-7 mm disc herniation with asymmetry towards the right, with a high intensity zone (HIZ) and impingement of the nerve root, an L4-5 5-6 mm disc herniation asymmetric towards the right, and an L1-2 3 mm disc protrusion asymmetric towards the right; and from the CT scan, a fusion of C5-6 and C6-7 levels, and a 2 mm disc/osteophyte complex at C6-7 and C7-T1.

Based on the diagnostic tests conducted on the patient on 10/6/2006, the neurosurgeon recommended a “trial of lumbar epidurogram and epidural and intra-thecal steroid injections at left L1, L4, and L5.”  On 10/17/2006, the neurosurgeon performed a left transforaminal lumbar epidurogram and epidural steroid injections at L1, L4, and L5, and a left provocative lumbar discograms and left intradiscal steroid injections at L1-2, L4-5, and L5-S1.  The neurosurgeon’s operative report stated that the discography “was found to be positive at L1, L4, and L5 levels.”  No control levels were noted.  The report also stated “the patient tolerated the procedure well and had some relief of low back and leg pain postoperatively.”

On 12/19/2006, the patient returned to the neurosurgeon’s office.  A “History and Physical Form” dated 12/19/2006, signed by the neurosurgeon, indicated that the patient had “some improvement” following his treatment in October 2006.  Nonetheless, the neurosurgeon recommended “transforaminal epidurograms and epidural and intradiscal steroid injections at L4-5, L5-S1, and L1-2.”  A “History of Physical Examination Report” dated 12/20/2006, noted “[i]ntractable and increasing low back and buttock pain with occasional tingling of the left leg and off and on numbness of the left last two fingers and some neck stiffness. Symptoms have been increasing for the last 4-5 weeks.”

On an Informed Consent form dated 12/19/2006, the procedure is listed as “Left transforaminal epidurograms and epidural and intradiscal steroid injects.”  On a patient information checklist signed on 12/19/2006, at “11:30 [sic]”, the procedure is described in identical language.  On another Informed Consent form also dated 12/19/2006, the procedure is listed as “Provocative lumbar discograms and microdecompressive lumbar discectomy.”  On a patient information checklist signed on 12/19/2006, at 4:20 p.m., the procedure is described as “Provocative lumbar discograms and microdecompressive lumbar discectomy.”

On 12/19/2006, the neurosurgeon performed “left transforaminal lumbar epidurograms and lumbar discogram of L4, L5, and transforaminal epidural and intradiskal [sic] steroid injection of L4, L5.”  No control levels were noted.  The operative report states that the discography “was found to be positive at 4, L5 levels” and that “the patient tolerated the procedure well and had some relief of low back and leg pain postoperatively.”  The patient scheduled a follow-up appointment with the neurosurgeon for 12/22/2006.  Apparently, the same day, 12/19/2006, the patient also scheduled surgery with the neurosurgeon for 12/21/2006.

In a “History and Physical Examination Report” dated 12/20/2006 and signed by the neurosurgeon on 12/23/2006, the neurosurgeon stated that the patient presented with “intractable and increasing low back and buttock pain with occasional tingling of the left leg and off and on numbness and tingling of the left last two fingers and some neck stiffness. Symptoms have been increasing for the last 4-5 weeks.”  The same report concluded that “If his lumbar disc symptoms progressively increase or worsen in spite of conservative treatment, then procedures of provocative lumbar discogram and microdecompressive lumbar discectomy will be indicated for the relief of his degenerative herniated lumbar disc symptoms.”

On 12/21/2006, the neurosurgeon performed a “provocative lumbar discogram and microdecompressive lumbar discectomy of L1, L4, and L5 under magnification [sic]”, from the left side. No control levels were noted.  In the neurosurgeon’s Operative Report for this procedure, he refers to the “L5” level, rather than the L5-S1 level.  The report stated that the discography resulted in “positive reproduction of preoperative pain and abnormal discogram of L1, L4, L5” and that “the patient tolerated the procedure well.”

In a “History and Physical Examination Report” dated 8/29/207, the neurosurgeon noted “some residual peroneal numbness and urinary problem [sic]” in the patient and found that he was suffering from “mild distress from spinal pain.”  Based on an MRI taken on 5/25/2007, the neurosurgeon noted 3 mm disc protrusion at L5-S1 and L4-5, and a 2 mm disc protrusion at L1-2.  No impingement of nerve roots was noted, but the “suggestion” of impingement was noted at L4-5.

On 8/30/2007, the neurosurgeon performed a “provocative lumbar discogram L4 and L5 and microdecompressive lumbar discectomy of L4 and L5 under magnification [sic]”, again from the left side.  In the neurosurgeon’s operative report for this procedure, he refers to the “L5” level instead of the L5-S1 level.  No control levels were noted.  The report states that the discography resulted in “grossly positive reproduction of preoperative pain and grossly abnormal discogram of L4 and L5” and that “the patient tolerated the procedure well.”

On 1/17/2008, the patient presented to the neurosurgeon again regarding his lower back and leg pain.  The neurosurgeon noted only “transient relief of his spinal symptoms” as a result of the two prior surgeries as well as “some urinary problem [sic].”  The neurosurgeon performed bilateral L3 and L4 medial branch and L5 ramus blocks.  The operative report stated that he performed “L3-4, L4-5, and L5-S1 facet nerve blocks”, and that “the patient tolerated the procedure well.”  The patient was scheduled for a follow-up appointment on 2/7/2008.

On 2/7/2008, the patient returned to the neurosurgeon’s office.  The “History and Physical Form” for this visit appears to be a copy of the one from 1/17/2008 with the dates changed, physical exam data updated, and the treatment plan stated as “bilateral lumbar facet injections (#2).”  No indication was stated for repeating this procedure.  The neurosurgeon again performed bilateral L3 and L4 medial branch and L5 ramus blocks.

On 3/12/2008, the patient returned again to the neurosurgeon’s office.  The “History and Physical Form” for this visit again was a copy of the one from 1/17/2008 with the dates changed, physical exam data updated, and the treatment plan stated as “lumbar radiofrequency ablation/denervation.”  No indication was stated for this procedure.  On 3/27/2008, the neurosurgeon performed bilateral lumbar facet L3, L4, and L5 denervation with thermocoagulation by radiofrequency.

On 2/5/2010, the patient underwent an MRI and EMG at the direction of the neurosurgeon.  There did not appear to be a “History and Physical Form” and for this visit.  The MRI report noted a 2-3 mm disc protrusion at L4-5 and a 4 mm disc protrusion at L5-S1.  The neurosurgeon performed a sacroiliac joint trigger point injection and stated “the patient tolerated the procedure well and had relief of pain.”

On 3/23/2010, the patient underwent right L3-4, L4-5, and L5-S1 facet blocks, an L5–S1 discogram, and a right L4-5 transforaminal epidural, which was performed by another physician.  The “History and Physical Form” for this visit appeared to be a copy of that from February and March 2008 with the dates changed, physical exam data updated, and the treatment plan stated as “right lumbar facet L3-4, L4-5, L5–S1 injection, right L5–S1 intradiscal steroid injection.”  The treatment plan appeared to be written in different handwriting from the rest of the form.  On 10/11/2010, the patient presented to the neurosurgeon again and underwent MRI scans of his lumbar spine with and without weight-bearing.  The scans showed right-sided 3-4 mm disc protrusion at L4–5 and L5–S1.

On 10/13/2010, the neurosurgeon prepared a typewritten “History and Physical Examination Form” that described the patient’s history as having involved pain in the right leg, not the left.  This report described the identical exam findings described in the original 10/6/2006 report but now reported them on the right side instead of the left.

On 10/14/2010, the neurosurgeon performed his third provocative lumbar discogram and microdecompressive lumbar discectomy procedure on the patient at L4-5 and L5-S1.  This procedure was performed for the first time on the right side of the two discs.  No control levels were noted.  The neurosurgeon noted in his operative report that discography resulted in “grossly positive reproduction of preoperative pain and gross abnormal discogram of L4-5 and L5-S1” and that “the patient tolerated the procedure well.”

The standard of care is to perform lumbar discography with adequate controls to produce a valid diagnostic study.  Lumbar discography is a controversial technique involving intradiscal injection of the contrast agent with fluoroscopy.  Suspect discs are injected with contrast agent, and the patient is asked to report if he or she is experiencing familiar pain.  Non-suspect discs are also injected as a control.  Production of concordant pain at a suspect level and lack of concordant pain at control levels is necessary to elicit a valid diagnostic study.  There is no documentation showing that the neurosurgeon ever injected a non-suspect disc as a control during any discography procedure with the patient.  By routinely failing to perform discography on non-suspect discs during discographic procedures, and thereby failing to perform valid diagnostic tests, the neurosurgeon departed from the standard of care.

The standard of care is to perform lumbar discectomy only with clear and appropriate indications.  Lumbar discectomy is indicated for the treatment of symptomatic nerve root impingement from disc derangement causing nerve root compression.  Patients should have symptoms and signs consistent with a specific dermatomal or myotomal distribution, such as pain, numbness, paresthesias, sensory loss, diminished reflexes, or weakness correlating to a specific nerve root.  Imaging studies should demonstrate pathology concordant to the level and side of the symptoms and signs.  The patient should have failed an adequate trial, typically 4 to 8 weeks at least, of conservative measures consisting of analgesics and physical therapy, unless emergent symptoms and signs of cauda equina syndrome are present.  Also, confounding factors should be factored into the decision-making process including, but not limited to, psychosocial factors that may magnify symptoms, such as depression, litigation, and Worker’s Compensation claims.

Various techniques of performing discectomy are utilized, including open, minimally invasive and percutaneous endoscopic methods.  Repeat discectomy is performed for either retained, unresected herniated disc material at the site of the original surgery, or recurrent disc herniation.  In the former circumstance, patients do not usually improve from the original surgery.  In the latter, patients typically have a period of pain relief followed by a recurrence of symptoms.  Repeat imaging should demonstrate the retained or recurrent disc herniation clearly discernible in comparison to the original images.  The requirement for concordance between the symptoms, signs, and imaging findings still applies.

The Medical Board of California judged that the neurosurgeon departed from the standard of care given that he performed lumbar discographies without controls and performed lumbar discectomies without clear and appropriate indications.

For this case and others, the Medical Board of California issued a public reprimand and ordered that the neurosurgeon complete a recordkeeping course within 6 months.

State: California


Date: May 2015


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain, Numbness, Extremity Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Unnecessary or excessive treatment or surgery, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Neurosurgery – Bowel And Bladder Incontinence Following Provocative Lumbar Discogram And Microdecompressive Lumbar Discectomy



On 5/16/2008, a 36-year-old male presented to a neurosurgeon with radiating pain in the right leg.  The neurosurgeon ordered a nerve conduction study and EMG report, which showed abnormalities consistent with irritation of L4, L5, and S1 nerve roots on both sides.  An MRI of the lumbar spine, with and without weight-bearing, showed a 2 mm disc protrusion with bilateral foraminal narrowing and central canal stenosis at L3-4, a 5-6 mm disc protrusion asymmetric to the right at L4-5, and a 4-5 mm disc protrusion with bilateral foraminal narrowing and impingement at L5-S1.  The neurosurgeon performed a sacroiliac joint trigger point injection.

On 6/9/2008, the patient returned to the neurosurgeon complaining of “intractable and increasing low back and right leg pain with numbness and tingling in the right foot and toes.”  The following day, the neurosurgeon performed “[p]rovocative lumbar discogram and microdecrompressive lumbar discectomy of L3, L4 and L5 [sic] under magnification.”  The neurosurgeon reported “grossly positive reproduction of preoperative pain and grossly abnormal discogram of L3, L4 and L5 noted.”  No control levels were noted.  The patient had no immediate complications and was discharged home the same day.

On 6/16/2008, the patient returned to the neurosurgeon and presented with [s]pinal headache and CSF [cerebrospinal fluid] leakage.”  The neurosurgeon performed an epidural blood patch.  On 7/18/2008, the neurosurgeon ordered a CT scan of the patient’s lumbar spine.  This study showed abnormalities with nerve impingement at L4-5 and L5-S1, and a 2 mm disc protrusion at L2-3 with foraminal narrowing and central canal stenosis.  The neurosurgeon performed a “para-lumbar vertebral nerve block procedure.”

On 7/21/2008, the patient returned to the neurosurgeon still complaining of “increasing low back and right leg pain with numbness and tingling of the right foot and toes as well as some aching of the right calf.”  The patient “did well for about 2 weeks” after his previous surgery, but “then developed recurrent and increasing spinal symptoms.”  The neurosurgeon ordered a repeat MRI study of the lumbar spine, which continued to show essentially the same abnormalities at L304, L405, and L5-S1 as had appeared in the pre-surgery MRI.

On 7/22/2008, the neurosurgeon again performed “[p]rovocative lumbar discogram and microdecompressive lumbar discectomy of L3, L4 and L5 [sic] under magnification.”  The neurosurgeon again reported “grossly positive reproduction of preoperative pain and grossly abnormal discogram of L3, L4, and L5 noted.”  Again, no control levels were noted.  Immediately following the surgery, the patient demonstrated urinary retention and reported numbness, but was discharged the same day.  On 7/23/2008, the patient reported to the neurosurgeon for his follow-up visit.  The neurosurgeon again noted “urinary retention”, but otherwise noted “neuro exam essentially normal.”  On 7/25/2008, the neurosurgeon ordered an additional MRI study of the patient’s lumbar spine.  This study again showed disc protrusion at L3-4, L4-5, and L5-S1 with foraminal narrowing, central canal stenosis, and nerve impingement at all three levels.

On 7/28/2008, the neurosurgeon ordered another MRI study of the patient’s lumbar spine.  This repeat MRI showed no significant change from the previous MRI of 7/25/2008.  The neurosurgeon noted numbness of the penis and perineal area and diagnosed “partial cauda equina syndrome.”  He recommended immediate, emergency decompressive surgery and referred the patient to a physician.  The same day, the patient presented to the physician and reported that he had experienced numbness in the groin immediately after the 7/22/2008 surgery with associated bowel and bladder incontinence, which persisted since then.  The patient expressed concern to the physician that his presenting symptoms had been “dismissed” by the neurosurgeon.  The physician diagnosed the patient with cauda equina syndrome.  The physician performed emergency laminectomies from L3-S1, discectomy of L4-5, and repair of cerebrospinal fluid leaks. Subsequently, the patient has continued to experience residual symptoms with ongoing fecal and urinary incontinence.

Cauda equina syndrome is a dangerous condition which can lead to permanent neurological deficit, including urinary and fecal incontinence.  Presentation with symptoms of cauda equina syndrome, including groin numbness and urinary hesitancy, constitute a medical emergency requiring immediate treatment.  Immediately following his second surgery on 7/22/2008, the patient presented with “urinary retention.”  When he was seen nearly a week later, on 7/28/2008, the patient stated he had also experienced groin numbness dating back to the date of the second surgery.  The neurosurgeon’s failure to diagnose his condition on or about 7/22/2009 and his delay in diagnosis until 7/28/2009 represent departures from the standard of care.

The standard of care is to perform lumbar discography with adequate controls to produce a valid diagnostic study.  Lumbar discography is a controversial technique involving intradiscal injection of the contrast agent with fluoroscopy.  Suspect discs are injected with contrast agent, and the patient is asked to report if he or she is experiencing familiar pain.  Non-suspect discs are also injected as a control.  Production of concordant pain at a suspect level and lack of concordant pain at control levels is necessary to elicit a valid diagnostic study.  There is no documentation showing that the neurosurgeon ever injected a non-suspect disc as a control during any discography procedure with the patient.  By routinely failing to perform discography on non-suspect discs during discographic procedures, and thereby failing to perform valid diagnostic tests, the neurosurgeon departed from the standard of care.

The standard of care is to perform lumbar discectomy only with clear and appropriate indications.  Lumbar discectomy is indicated for the treatment of symptomatic nerve root impingement from disc derangement causing nerve root compression.  Patients should have symptoms and signs consistent with a specific dermatomal or myotomal distribution, such as pain, numbness, paresthesias, sensory loss, diminished reflexes, or weakness correlating to a specific nerve root.  Imaging studies should demonstrate pathology concordant to the level and side of the symptoms and signs.  The patient should have failed an adequate trial, typically 4 to 8 weeks at least, of conservative measures consisting of analgesics and physical therapy, unless emergent symptoms and signs of cauda equina syndrome are present.  Also, confounding factors should be factored into the decision-making process including, but not limited to, psychosocial factors that may magnify symptoms, such as depression, litigation, and Worker’s Compensation claims.

Various techniques of performing discectomy are utilized, including open, minimally invasive and percutaneous endoscopic methods.  Repeat discectomy is performed for either retained, unresected herniated disc material at the site of the original surgery, or recurrent disc herniation.  In the former circumstance, patients do not usually improve from the original surgery.  In the latter, patients typically have a period of pain relief followed by a recurrence of symptoms.  Repeat imaging should demonstrate the retained or recurrent disc herniation clearly discernible in comparison to the original images.  The requirement for concordance between the symptoms, signs, and imaging findings still applies.

The Medical Board of California judged that the neurosurgeon departed from the standard of care given that he performed lumbar discographies without controls and performed lumbar discectomies without clear and appropriate indications.

For this case and others, the Medical Board of California issued a public reprimand and ordered that the neurosurgeon complete a recordkeeping course within 6 months.

State: California


Date: May 2015


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Extremity Pain, Numbness, Back Pain, Urinary Problems


Diagnosis: Spinal Injury Or Disorder, Post-operative/Operative Complication


Medical Error: Unnecessary or excessive treatment or surgery, Delay in proper treatment, Underestimation of likelihood or severity, Lack of proper documentation, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



California – Neurosurgery – Provocative Lumbar Discogram And Microdecompressive Lumbar Discectomy For Low Back Pain And Extremity Pain



On 5/4/2011, a 55-year-old female presented to a neurosurgeon with complaints of “intractable and increasing low back and right leg greater than left leg pain with tingling and burning sensation of both feet, right greater than left and frequent ‘Charlie horse’ on both leg/calf, lower mid-back pain with muscle spasm, intractable and increasing neck and left upper extremity pain with weakness of both handgrips, left greater than right (dropping things), associated with daily fronto-occipital pressure/throbbing headaches.”  The neurosurgeon ordered x-ray imaging of the thoracic, cervical, and lumbar spine, EMG, bone densitometry, and MRI of the lumbar and cervical spine.  The MRI study showed a 3 mm disc protrusion with “borderline” spinal stenosis at L3-4, a 5 mm disc protrusion with “high grade” spinal stenosis and moderate bilateral neuroforaminal exit zone compromise at L4-5, and a 3 mm disc protrusion at L5-S1.  The neurosurgeon diagnosed the patient with “severed advanced degenerative lumbar disc herniations, L3, L4, L5/spondylosis/lumbar stenosis, L3-4 and L4-5 lateral and central with neurogenic claudication and lumbar radiculopathy.”

On 5/5/2011, the neurosurgeon performed “Provocative lumbar discogram of L3, L4, and L5 and microdecompressive lumbar discectomy of L3, L4, L5 [sic]”; “Right and left foraminoplasty L3-4, L4-5”; “Partial vertebrectomy of right and left L3-4 and L4-5 for decompressive foraminoplasty”; and “Lumbar laminotomy, L4-5, L4-5 levels [sic], bilaterally, with minimally invasive lumbar decompression (MILD) and excision of hypertrophic ligamentum flavum at L3-4 and L4-5 bilaterally.”  The neurosurgeon reported “gross positive reproduction of preoperative pain and grossly abnormal discogram of L3, L4 and L5 noted.”  No control levels were noted.  The patient had no immediate complications and was discharged home the same day.

On 5/6/2011, the neurosurgeon performed a sacroiliac joint trigger point injection on the patient.  The operative report noted that “the patient tolerated the procedure well and had relief of pain.”

On 7/20/2011, the patient returned to the neurosurgeon reporting “recurrent intractable and increasing low back/right hip and right lower extremity pain and some left leg pain with muscle spasm and some difficulty with urination.”  The patient reported that the surgery of 5/5/2011, “did give her some transient relief of her spinal symptoms for about 4-5 days.”  The neurosurgeon ordered repeat x-ray imaging and an MRI of the lumbar spine as well as an EMG.  The MRI showed no significant change compared to the preoperative study: a broad, 4-5 mm disc protrusion with “moderate to high grade” spinal stenosis and bilateral neuroforaminal exit zone compromise at L3-4; a broad, 5-6 mm disc protrusion with “high grade” stenosis and “moderate” bilateral neuroforaminal exit zone compromise at L4-5; and a broad, 4-5 mm disc protrusion at L5-S1.

On 7/21/2011, the neurosurgeon performed “[p]rovocative lumbar discogram and microdecompressive lumbar discectomy of L3, L4 and L5 [sic]” and “[b]ilateral lumbar facet L3, L4, L5 nerve blocks.”  Again, the neurosurgeon reported “grossly positive reproduction of preoperative pain and grossly abnormal discogram of L3, L4 and L5 noted.”  No control levels were noted again.  The patient had no immediate complications and was discharged home the same day.  A post-operative MRI was performed on 7/22/2011, which showed reduced disc bulges at L3-4 and L4-5, but continuing stenosis and bilateral neuroforaminal exit zone compromise.

On 8/19/2011, the patient presented to her primary care physician, reporting continuing severe back pain.  The patient was referred back to the neurosurgeon, who, on 8/23/2011, ordered additional thoracic and lumbar spine MRI scans.  The thoracic spine MRI showed a 3 mm disc bulge at T8-9 and disc narrowing and degeneration at T7-8, T8-9, and T9-10.  The lumbar spine MRI was unchanged from the prior MRI on 7/22/2011.  The neurosurgeon referred the patient to another neurosurgeon.  The patient was also seen by an infectious disease specialist.  The patient was placed on a course of antibiotics, and a PICC line was installed, with a diagnosis of possible discitis. Her pain issues remained unresolved.

The standard of care is to perform lumbar discography with adequate controls to produce a valid diagnostic study.  Lumbar discography is a controversial technique involving intradiscal injection of the contrast agent with fluoroscopy.  Suspect disc are injected with contrast agent, and the patient is asked to report if he or she is experiencing familiar pain.  Non-suspect disc are also injected as a control.  Production of concordant pain at a suspect level and lack of concordant pain at control levels is necessary to elicit a valid diagnostic study.  There is no documentation showing that the neurosurgeon ever injected a non-suspect disc as a control during any discography procedure with the patient.  By routinely failing to perform discography on non-suspect discs during discographic procedures, and thereby failing to perform valid diagnostic tests, the neurosurgeon departed from the standard of care.

The standard of care is to perform lumbar discectomy only with clear and appropriate indications.  Lumbar discectomy is indicated for the treatment of symptomatic nerve root impingement from disc derangement causing nerve root compression.  Patients should have symptoms and signs consistent with a specific dermatomal or myotomal distribution, such as pain, numbness, paresthesias, sensory loss, diminished reflexes, or weakness correlating to a specific nerve root.  Imaging studies should demonstrate pathology concordant to the level and side of the symptoms and signs.  The patient should have failed an adequate trial, typically 4 to 8 weeks at least, of conservative measures consisting of analgesics and physical therapy, unless emergent symptoms and signs of cauda equina syndrome are present.  Also, confounding factors should be factored into the decision-making process including, but not limited to, psychosocial factors that may magnify symptoms, such as depression, litigation, and Worker’s Compensation claims.

Various techniques of performing discectomy are utilized, including open, minimally invasive and percutaneous endoscopic methods.  Repeat discectomy is performed for either retained, unresected herniated disc material at the site of the original surgery, or recurrent disc herniation.  In the former circumstance, patients do not usually improve from the original surgery.  In the latter, patients typically have a period of pain relief followed by a recurrence of symptoms.  Repeat imaging should demonstrate the retained or recurrent disc herniation clearly discernible in comparison to the original images.  The requirement for concordance between the symptoms, signs, and imaging findings still applies.

The Medical Board of California judged that the neurosurgeon departed from the standard of care given that he performed lumbar discographies without controls and performed lumbar discectomies without clear and appropriate indications.

For this case and others, the Medical Board of California issued a public reprimand and ordered that the neurosurgeon complete a recordkeeping course within 6 months.

State: California


Date: May 2015


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Extremity Pain, Headache, Back Pain, Head/Neck Pain, Weakness/Fatigue


Diagnosis: Spinal Injury Or Disorder, Infectious Disease


Medical Error: Unnecessary or excessive treatment or surgery, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Neurosurgery – Lumbar Discectomy For A Patient With Spinal Stenosis At Every Disc Except L2-3



On 10/17/2011, a 75-year-old female was referred to a neurosurgeon.  She complained of “intractable and increasing low back/right buttock/right leg burning/aching pain and some lower mid-back pain with muscle spasm.”  The neurosurgeon ordered an EMG study, a CT scan and an MRI of the lumbar spine, x-ray imaging of the thoracic, cervical, and lumbar spine, and a bone densitometry study.  The MRI showed 4-5 mm protrusions with neuroforaminal exit zone compromise at every disc from L1-L2 to L5-S1.  Spinal stenosis was noted at every disc except L2-3.

On 10/18/2011, the neurosurgeon performed “[p]rovocative lumbar discogram and microdecompressive lumbar discectomy and foraminoplasty for enlargement of the foramen of L1, L2, L3, L4 and L5 under magnification [sic].”  The neurosurgeon reported “grossly positive reproduction of preoperative pain and grossly abnormal discogram of L1, L2, L3, L4 and L5 noted.”  No control levels were noted.  The patient had no immediate complications and was discharged home the same day.

The standard of care is to perform lumbar discography with adequate controls to produce a valid diagnostic study.  Lumbar discography is a controversial technique involving intradiscal injection of the contrast agent with fluoroscopy.  Suspect discs are injected with contrast agent, and the patient is asked to report if he or she is experiencing familiar pain.  Non-suspect discs are also injected as a control.  Production of concordant pain at a suspect level and lack of concordant pain at control levels is necessary to elicit a valid diagnostic study.  There is no documentation showing that the neurosurgeon ever injected a non-suspect disc as a control during any discography procedure with the patient.  By routinely failing to perform discography on non-suspect discs during discographic procedures, and thereby failing to perform valid diagnostic tests, the neurosurgeon departed from the standard of care.

The standard of care is to perform lumbar discectomy only with clear and appropriate indications.  Lumbar discectomy is indicated for the treatment of symptomatic nerve root impingement from disc derangement causing nerve root compression.  Patients should have symptoms and signs consistent with a specific dermatomal or myotomal distribution, such as pain, numbness, paresthesias, sensory loss, diminished reflexes, or weakness correlating to a specific nerve root.  Imaging studies should demonstrate pathology concordant to the level and side of the symptoms and signs.  The patient should have failed an adequate trial, typically 4 to 8 weeks at least, of conservative measures consisting of analgesics and physical therapy, unless emergent symptoms and signs of cauda equina syndrome are present.  Also, confounding factors should be factored into the decision-making process including, but not limited to, psychosocial factors that may magnify symptoms, such as depression, litigation, and Worker’s Compensation claims.

Various techniques of performing discectomy are utilized, including open, minimally invasive and percutaneous endoscopic methods.  Repeat discectomy is performed for either retained, unresected herniated disc material at the site of the original surgery, or recurrent disc herniation.  In the former circumstance, patients do not usually improve from the original surgery.  In the latter, patients typically have a period of pain relief followed by a recurrence of symptoms.  Repeat imaging should demonstrate the retained or recurrent disc herniation clearly discernible in comparison to the original images.  The requirement for concordance between the symptoms, signs, and imaging findings still applies.

The Medical Board of California judged that the neurosurgeon departed from the standard of care given that he performed lumbar discographies without controls and performed lumbar discectomies without clear and appropriate indications.

For this case and others, the Medical Board of California issued a public reprimand and ordered that the neurosurgeon complete a recordkeeping course within 6 months.

State: California


Date: May 2015


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain, Extremity Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Unnecessary or excessive treatment or surgery, Lack of proper documentation, Procedural error


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Anesthesiology – Methadone For Post-Operative Pain



In October 2013, the Board received a report of a malpractice settlement payment.

On 09/02/2010, a patient presented to an ambulatory surgical center for a tonsillectomy and adenoidectomy.  The surgeon consulted with the anesthesiologist for appropriate pain medication for the patient following the procedure.  The anesthesiologist recommended methadone 10 mg 1-2 tablets every 8 hours as needed for pain.  The patient was sent home with a prescription for methadone 10 mg.

On 09/04/2010, the patient died.  An autopsy determined that the patient’s death was caused by respiratory depression due to methadone drug overdose.

The chart was submitted to an independent reviewing expert who concluded that the anesthesiologist’s conduct fell below the standard of care.

The anesthesiologist was reprimanded.

State: North Carolina


Date: May 2015


Specialty: Anesthesiology


Symptom: Pain


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Lack of proper documentation


Significant Outcome: Death


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Radiology – Missed Finding Leads To Deterioration Of A Patient After A Gastric Bypass



On 10/17/2013, a professional liability payment was made.

A 45-year-old female underwent laparoscopic gastric bypass procedure by a general surgeon.  Several weeks after the surgery, the patient was taken to the emergency department of another hospital with complaints of severe left-sided upper and lower abdominal pain and nausea.  The emergency department physician ordered an abdominal and pelvis CT scan.

A radiologist was providing night teleradiology coverage to the hospital and was called to interpret CT scan.  The radiologist reported that there was no free intraperitoneal air.  The patient deteriorated and was transferred to the intensive care unit with sepsis.

An independent medical expert indicated that the presence of free air was visible on the CT scan and should have been communicated to the surgeon.

The Board expressed concern that the radiologist’s conduct was below the minimum standard of competence given failure to detect and report the finding of free intraperitoneal air on a CT scan.

The Board issued a public letter of concern, which was reported to the Federation of State Medical Boards.  It was not reported to the National Practitioner Data Bank.

State: North Carolina


Date: May 2015


Specialty: Radiology


Symptom: Abdominal Pain


Diagnosis: Acute Abdomen, Sepsis, Post-operative/Operative Complication


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



North Carolina – Psychiatry – Dosing Of Psychiatric Medications For A Three Year Old



On 05/14/2014, a three-year-old patient presented to a psychiatrist for an evaluation.  The patient’s mother complained of problems with attention, erratic sleep schedule, and aggression towards the patient’s younger sibling.

The psychiatrist diagnosed the patient with attention deficit hyperactivity disorder (ADHD) and prescribed two psychostimulant medications with a recommendation for a follow-up within a month.

On 09/16/2014, the psychiatrist saw the patient, who presented with complaints of trouble sleeping, diminished appetite, and diminished energy level.  The patient’s mother had consulted another physician, who discontinued one of the ADHD medications, because the dosage was considered too high for the patient.  The psychiatrist then discontinued both of the medications that the psychiatrist had initially prescribed for the patient and started the patient on a third psychostimulant medication for ADHD.

On 10/28/2014, the patient returned to the psychiatrist, who discontinued the third medication he had prescribed and prescribed a fourth psychostimulant medication for ADHD.  The psychiatrist also prescribed two new antidepressant medications at dosages recommended for an adult.  Within 48 hours of taking these three prescriptions, the patient became ill and was hospitalized due to an altered mental status.

In November 2014, the Board received complaints regarding the care provided by the psychiatrist.  The complaints were from two of the patient’s treating physicians.  The patient’s medical records were sent to an independent medical expert who specializes in child psychiatry.  This independent medical expert opined that all aspects of the psychiatrist’s care for the patient were below the acceptable and prevailing standard of care in North Carolina.

The medical expert opined that the psychiatrist did not conduct a complete and thorough evaluation of the patient.  The diagnosis of ADHD in a three year old requires collateral information which was not obtained.  The expert opined that the medication choices for the patient were below the standard of practice.  Stopping one medication and starting a combination of three medications at adult dosage levels in a three year old lead to serious iatrogenic side effects requiring hospitalization.

The Board required that the psychiatrist complete 15 hours of Category 1 CME in the diagnosis and treatment of ADHD with a 6 month time limit.

State: North Carolina


Date: May 2015


Specialty: Psychiatry


Symptom: Allergic Reaction Symptoms


Diagnosis: Autoimmune Disease


Medical Error: Improper medication management


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Pennsylvania – Neurosurgery – Malpositioning Of L3-4 graft During Operation Leads To Subsequent Loss Of Nerve Function



A patient had severe lumbar pain when he began receiving medical care and treatment from a neurosurgeon.

The lumbar pain did not improve with conservative treatment.  The patient underwent diagnostic studies, including a lumbar x-ray, several lumbar MRI’s, an EMG, and a discogram, which were reviewed by the neurosurgeon.

The discogram was indeterminant as to whether there existed, at any level of the patient’s lumbar spine, a condition at the L4-5 level that would be appropriate for surgical intervention, even as a part of any spinal fusion procedure.

The neurosurgeon advised and/or offered the patient a surgical approach to his symptoms and/or complaints.

On 9/23/2009, the neurosurgeon performed a posterior L3 through S1 decompression and fusion with percutaneous instrumentation at the L3-4, L4-5, and L5-S1 levels.

The neurosurgeon performed intra-operative neurophysiological monitoring, which included manipulation of spinal nerves, in order to determine how well they were functioning.  During the course of the surgery, multiple episodes of abnormal nerve function were noted and communicated to the neurosurgeon.

Each of the aforementioned episodes of abnormal nerve function resolved within a few minutes with occasional surgical pauses and no surgical intervention.

Subsequently during the surgery, following the placement and removal of the L3-4 interbody graft, the patient sustained a complete loss of nerve function due to manipulation by the neurosurgeon.

The neurosurgeon acknowledged he had malpositioned the L3-4 graft and the subsequent loss of nerve function.  He took a surgical pause, during which 10 mg of Decadron was administered by anesthesia at the neurosurgeon’s request.

Following the surgical pause, the neurosurgeon elected to continue with the surgery.

The affected nerve and muscles were those that control the patient’s ability to move his ankles and toes.  The patient had not regained movement of his lower extremities by the day following surgery.

Post-operative diagnostic imaging studies of the patient demonstrated pressure on his lumbar nerve roots on the right side, which was more likely than not contributing to the patient’s right leg paralysis.

The neurosurgeon failed to return the patient to surgery to decompress the right-side lumbar nerve roots.  At any formal hearing of this matter, the Commonwealth would argue that the neurosurgeon’s treatment and care of the patient departed from a quality standard of the profession in that the neurosurgeon recommended a surgical procedure and later performed that procedure in a manner beneath the standard of care.

It was recommended that the neurosurgeon complete an initial assessment and clinical skills assessment through the Life Guard program of the Pennsylvania Medical Society and complete any remedial training recommended by Life Guard.

State: Pennsylvania


Date: May 2015


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Post-operative/Operative Complication, Spinal Injury Or Disorder


Medical Error: Procedural error, Delay in proper treatment


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



California – Pain Management – Stolen Leads Used For Temporary Spinal Cord Stimulator



On 2/17/2011, a pain management specialist percutaneously implanted temporary spinal cord stimulator leads in a patient’s epidural space.  The temporary leads were implanted for a trial period to assess whether stimulation would relieve the patient’s intractable back, hip, and lower extremity pain.

The leads themselves were supplied by a terminated employee of Boston Scientific, who had stolen them from that company.  The pain management specialist knew that the employee had been terminated and that the leads came from Boston Scientific. The pain management specialist nonetheless purchased the leads (as well as numerous other items) directly from the employee, and not through Boston Scientific, for a sum which was a small fraction of their usual cost.

The pain management specialist never confirmed with Boston Scientific whether the leads were legitimately in the possession of the employee, and in fact, told a Boston Scientific representative that he was using another company’s products in the patient’s implantation procedure.  The pain management specialist then allowed the employee, who had no medical license, to assist him in the patient’s procedure, but misrepresented his identity in his operative notes, calling him “John Simpson.” The pain management specialist also used leads that had expired two years before, and allowed a licensed massage therapist, who had no other medical certification or license, to position the C-Arm Fluoroscope during the procedure.  He also allowed a licensed Physician Assistant to administer the anesthetic (which was propofol, a potent narcotic) to the patient. The pain management specialist did not sign the anesthesia record indicating that he was the supervising physician.

The following day, the Boston Scientific representative called officers from the police department to go to the pain management specialist’s office to recover medical equipment and supplies worth approximately $143,980.  The Boston Scientific Representative had been informed that these were in the pain management specialist’s possession by one of his employees. The pain management specialist initially refused to allow the officers access his premises, but relented when the officers indicated that they would obtain a search warrant if the pain management specialist did not voluntarily allow them to proceed.  The items were removed and returned to Boston Scientific.

Allowing the employee with no medical license to assist in the implantation, and implanting expired leads in the patient were an extreme departure from the applicable standard of care and placed the patient’s health and safety at risk.

For this allegation and others, the State Board of California ordered that the pain management specialist be placed on probation for five years and attend a professionalism program (ethics course), as well as a prescribing practices course, be assigned a practice monitor, and maintenance of records of controlled substances.  During this time, the pain management specialist was prohibited from supervising physician assistants.

State: California


Date: May 2015


Specialty: Pain Management


Symptom: Back Pain, Extremity Pain, Joint Pain


Diagnosis: N/A


Medical Error: Ethics violation, Improper supervision


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



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