Found 103 Results Sorted by Case Date
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California – Neurology – Neck Pain, Extremity Weakness, And Numbness Diagnosed As Multiple Sclerosis



A 56-year-old female was referred by her primary care physician to a neurologist.  The patient’s primary care physician noted neck pain and numbness of the upper extremities, left greater than right, present for 1 year.  Her medications were lisinopril 5 mg daily, Lyrica 50 mg 3 times daily, Flexeril 10 mg 3 times daily, Mobic 15 mg daily, and Nexium 40 mg daily.  Her primary care physician noted that she had lumbar laminectomy for disk herniation in the past for low back pain and tingling of the left leg. He also noted that the MRI of her cervical spine was abnormal and requested a neurological evaluation.  It revealed an abnormal signal intensity C2-3 affecting posterior columns with the radiologist’s comment of “could account for arm numbness and tingling.” The x-ray of her cervical spine performed on 11/5/2012 ordered by her primary care physician showed moderate degenerative changes.  The x-ray of her lumbar spine performed on 2/23/2012 showed similar findings.

The neurologist first saw the patient on 12/10/2012 for the abnormal cervical spine MRI.  The patient’s complaints were “neck pain; left neck and arm numb; right arm and right knee; losing urine; and generalized weakness on the left.”  The patient also complained that she “also feels ‘dead’ hips down, [d]izzy spells several times, no energy, difficult to concentrate.” The neurologist noted the “neuro exam essentially normal.”  The neurologist’s diagnoses were demyelinating disease; paresthesias of face and her extremities, vertigo, and memory loss. The neurologist ordered the following tests: EMG/NCV lower extremities, though later she also did upper extremities; MRI of the brain; neuromuscular junction tests with EMG; BAER with vestibular testing; VEP; EEG, overnight; and EEG awake and sleep with digital analysis 95957.

The upper extremity EMG/NCV study was performed on 1/3/2013.  She tested 4 motor nerves, 5 sensory nerves, and F waves. The neurologist tested every muscle, which was present in the upper extremities.  The results of the study were normal.

The electrodiagnostic study of the lower extremities were performed on 1/10/2013.  The neurologist tested 4 motor nerves, 6 sensory nerves, 2 H reflexes, bilateral F waves of the motor nerves.  She did a needle EMG of all muscles in the lower extremities and paraspinal muscles. The results of the study were normal.

There was a report of a video-monitored EEG utilizing a 32-channel digital EEG system manufactured by Cadwell.  This test was performed on 12/26/2012. The report stated that the technician performed hyperventilation, but the patient reported she did not, and that the patient was videotaped, though the patient reported she was not.  It was read as normal.

The ambulatory EEG was performed on 2/5/2013 to 2/6/2013.  In the report, it was termed a 2-day ambulatory EEG despite lasting only 1 day.  The neurologist prepared the report. The report contained a printout of 1 page. It was timed 6:21 a.m., and it contained widespread artifacts lasting 10 seconds.  This was the exact time that the patient reported she stood in front of her microwaves. The neurologist read this as “Isolated sharp waves were noted in the frontal left hemispheric area. The isolated sharp waves may be epileptogenic in nature.”  The visual and brainstem auditory evoked potentials were normal.

On 2/26/2013, the neurologist saw the patient for a follow-up visit.  The test results were available to the neurologist at the visit. The neurologist noted that the EEG for the patient was normal for both awake and drowsy.  The neurologist also noted that the 2-day EEG, which lasted only 1 day and the MRI of the brain showed a corpus callosum lesion. Her assessment and plan contained the same diagnoses as the first visit of 12/10/2012, and she failed to consider new information that should have changed her initial diagnoses.

The neurologist did not diagnose seizures in the assessment and plan, but she prescribed Depakote.  The neurologist discussed with the patient that she met criteria for relapsing and remitting Multiple Sclerosis with an acute exacerbation.  The neurologist also noted that the patient had pain with neck movement, which was sharp and went to the toes. She believed that the symptom was consistent with the finding of the ambulatory EEG and thus started the patient on Depakote 500 mg b.i.d.  The neurologist failed to recognize Lhermitte’s sign, consistent with the myelopathy. The neurologist ordered laboratory studies for Lyme disease, lupus, and lumbar puncture. She ordered monitoring labs for Depakote, CBC, and liver function tests to be done before the next visit.

The MRI of the brain the neurologist referred to in the 2/26/2013 follow-up visit was performed at the neurologist’s request on 12/28/2012.  The report indicated 20 FLAIR hyperintensities and a possible tiny corpus callosum lesion. The neurologist concluded it was consistent with multiple sclerosis.  The 12/28/2012 report contained a comparison to a previous MRI of the brain performed on 7/1/2007. The radiologist thought the new MRI showed abnormalities “probably very slightly more numerous” than the 2007 MRI.  He further considered the appearance to be nonspecific, and the tiny lesion in the corpus callosum was considered possible.

The 2007 MRI was requested by another physician.  It was read as showing “a few nonspecific scattered punctate of unlikely clinical significance.”  Multiple sclerosis was not raised as a possible cause. Referring diagnosis was “recent vertigo and left-sided dizziness.”  The neurologist failed to question the patient on symptoms that occurred in 2007.

On 3/12/2013, the patient was seen in the emergency room for nausea and vomiting.  She was diagnosed with Depakote toxicity with a level of 108. She was told to stop the medication.  She was scheduled for the lumbar puncture the following day and was told to keep that appointment. The day following the lumbar puncture, she developed symptoms consistent with a postspinal headache.  She was seen by the neurologist in her office on the same day and diagnosed with Depakote toxicity. At this point, the neurologist erroneously believed that the patient had “definite” multiple sclerosis.  She also erroneously believed that “the patient wrongfully assumed” Depakote caused her symptoms and believed that they were from the lumbar puncture.

The neurologist next saw the patient on 3/26/2013 for an office visit.  The neurologist noted that the patient had a postspinal headache. She noted that the spinal fluid was negative for oligoclonal bands, but incorrectly thought the IgG synthesis was abnormal.  She incorrectly diagnosed “primary stabbing headache” despite her earlier entry of postspinal headache.

In a subsequent interview with a Medical Board investigator, the neurologist was questioned as to why she did not take a history of previous symptoms, such as optic neuritis, that help to establish a diagnosis of multiple sclerosis.  She was questioned if the examination was normal and why she did not check the “saddle” area for sensory loss, and she reported, “Why should I check the saddle area?” There were no “incontinence of stools.” When asked if she would have documented Lhermitte’s symptom or sign if present, she answered yes.  She obtained a history of symptoms consistent with Lhermitte’s, but did not recognize it as such. Memory loss was given as a diagnosis, but when asked how it was based, she could not recall. When asked to explain the reasons that each test was ordered, she responded that the EMG was based on symptoms, the neuromuscular test was based on the possibility of myasthenia gravis causing general weakness, the BAER and VEP as part of the multiple sclerosis work-up, and the EEG to rule out seizures as the cause of numbness and weakness.  She stated video monitoring on EEG was standard practice. Hearing loss was her reason for performing the BAER, but no hearing loss or visual disturbance was documented. She stated that the 2007 MRI showed infratentorial and supratentorial lesions whereas there was no mention of an infratentorial lesion in the radiology report. She ordered the EMG of the upper extremities to “rule out any other diseases” and stated “EMG is part of differential diagnosis,” and the indication she believed was numbness and tingling in the hands. When asked why she did 24 upper extremity and 6 cervical paraspinal muscles on EMG, she stated she wanted to make sure there was “no polyradiculopathy,” but she admitted there were no findings to suggest that diagnosis.  Further, she believed that numbness and tingling and incontinence would indicate polyradiculopathy. When questioned regarding indications for EMG of the lower extremities, she stated back problems, numbness right arm and right knee, and feeling the hips on down were “dead.” In the lower extremities, she tested 12 different muscles and 6 paraspinal muscles. She was then questioned about what were the indications for the EEG, and she believed they were generalized weakness, dizzy spells, no energy to work, and difficulty focusing. She was questioned as to why the first EEG was not sufficient. She stated that on 2/26/2013 visit, she had findings of generalized seizure disorder, but this was not the wording in the EEG report nor was it in her letter to the Board.  She was not aware that a microwave can cause artifacts. Regarding indication for Depakote, her answer was because of the EEG and numbness and tingling. She thought it would be trial and error to see if it would help. She thought that the patient’s symptom of “neck killing her” would be consistent with a multiple sclerosis plaque. When asked why she ordered Lyme disease and lupus blood tests, she stated that they were “on my mind.”

The Medical Board of California judged that the neurologist’s conduct departed from the standard of care because she failed to recognize symptoms and findings on the MRI of a partial transverse cervical myelopathy, ordered an EMG for the upper and lower extremities, video EEG, and ambulatory EEG without medical indication, conducted an excessive number of nerve tests for any diagnosis, misdiagnosed epilepsy, lacked knowledge in reading EEGs, and had no knowledge and/or did not consider the important interaction between Depakote and the patient’s other medications.  The neurologist also lacked knowledge in several fundamental areas.  She failed to recognize symptoms of a partial transverse cervical myelopathy and Lhermitte’s symptoms even though it was described to her by the patient.  She did not recognize or, if she did, did not reflect in her records that almost all of the patient’s symptoms were caused by the cervical myelopathy. The neurologist erroneously believed that a multiple sclerosis plaque could cause severe neck pain and that IgG synthesis could indicate active or inactive multiple sclerosis.  She diagnosed multiple sclerosis on the basis of the McDonald criteria, and she included the original report, but she gave no information in her records how those criteria fit the patient. She failed to question the patient for previous symptoms, which might establish an initial exacerbation of multiple sclerosis. The neurologist was aware that the patient had an MRI in 2007 and did not question the patient regarding her symptoms at that time.  She ordered laboratory studies for possible Lyme disease or “lupus” and a monophasic cervical myelopathy despite the fact that it was exceedingly unlikely to be caused by any of those disorders. She failed to consider alternative causes for the patient’s presentation, specifically B12 deficiency or adrenomyeloneuropathy.

For this case and others, the Medical Board of California placed the neurologist on probation and ordered the neurologist to complete a medical record keeping course, a professionalism program (ethics course), an education course (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.  The neurologist was assigned a practice monitor and was prohibited from supervising physician assistants and advanced practice nurses.

State: California


Date: January 2018


Specialty: Neurology


Symptom: Head/Neck Pain, Dizziness, Headache, Nausea Or Vomiting, Numbness, Urinary Problems, Weakness/Fatigue


Diagnosis: Spinal Injury Or Disorder, Drug Overdose, Side Effects, or Withdrawal


Medical Error: Diagnostic error, Failure to examine or evaluate patient properly, Unnecessary or excessive diagnostic tests, Improper medication management


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Anesthesiology – Wrong Site Procedure For A Transforaminal Epidural Steroid Injection



On 4/28/2015 an 80-year-old female, presented to an anesthesiologist for an initial consultation for possible epidural steroid injections.  On 4/28/2015, the patient had a history of left sided lower back pain and left lower extremity pain.

On 4/28/2015, the anesthesiologist scheduled the patient for a left transforaminal epidural steroid injection (TFESI) to be performed on 4/29/2015.

On 4/29/2015, the patient presented to the anesthesiologist at outpatient surgery and laser center for the planned left TFESI.  On 4/29/2015, the patient and anesthesiologist signed a consent form for a left TFESI.  After the patient was prepped for the procedure, the anesthesiologist performed a TFESI on the patient’s right side (the wrong site).  While the patient was still in the procedure room, the anesthesiologist was informed that he performed the TFESI on the incorrect side.  The anesthesiologist then performed a TFESI on the patient’s left side (the correct site).

The anesthesiologist’s procedure report on 4/29/2015 procedures did not accurately document the anesthesiologist’s performance of TFESI procedures on two different sides of the patient.

The Board ordered the anesthesiologist to pay a fine of $5,000 against his license.  Also, the Board ordered that the anesthesiologist pay reimbursement costs of $5,857.63.  The Board ordered that the anesthesiologist complete a medical records course.  The Board ordered that the anesthesiologist complete five hours of continuing medical education on “Risk Management.”  Also, the Board ordered the anesthesiologist to complete a one hour lecture on wrong site surgeries to medical staff at an approved site.

State: Florida


Date: December 2017


Specialty: Anesthesiology, Neurology


Symptom: Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Obstetrics – Lack Of Maternal Serum Alpha-Fetoprotein Testing With Pregnancy Complications



On 2/24/2014, a 36-year-old female presented to an obstetrician for fatigue, breast tenderness, and absence of menstruation.  At the aforementioned visit, the obstetrician diagnosed the patient with amenorrhea and sent her to have blood work.

On 2/25/2014, the patient was notified of her positive pregnancy test.

On 3/10/2014, 3/17/2014, 3/24/2014. 4/24/2014, 8/7/2014, and 9/25/2015, the obstetrician ordered obstetrical ultrasounds and/or sonograms for the patient.

On 4/23/2014 and 8/20/2014, the patient presented to the obstetrician with thick vaginal fluid and blood discharge, morning sickness, nausea, chills, fever, and back pain.

On 5/23/2014, 6/20/2014, 7/16/2014, 8/15/2014, 9/12/2014, 10/13/2014, 10/20/2014, and 10/27/2014, the patient presented to the obstetrician for follow-up visits.

On 11/2/2014, the patient gave birth to her son, who was born with spina bifida/myelomeningocele.

The obstetrician failed to diagnose neural tube defect on imaging studies.

The obstetrician failed to order a maternal serum alpha-fetoprotein (MSAFP) test and did not maintain adequate legible documentation of ordering an MSAFP test.

The obstetrician failed to order an anatomical survey sonogram.

The Board ordered that the obstetrician pay a fine of $7000 against his license. The Board ordered that the obstetrician pay reimbursements costs of a minimum of $3,786.18 and not to exceed $5,786.18.  The Board also ordered that the obstetrician complete a course on “Quality Medical Record Keeping for Health Care Professionals” and that he  complete five hours of continuing medical education on “Risk Management.”

State: Florida


Date: December 2017


Specialty: Obstetrics


Symptom: Fever, Bleeding, Nausea Or Vomiting, Back Pain


Diagnosis: Obstetrical Complication, Spinal Injury Or Disorder


Medical Error: Failure to order appropriate diagnostic test, Failure to follow up, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Virginia – Neurosurgery – All-Terrain Vehicle Rollover Accident Causes L1 Compression Fracture



On 1/19/2008, a 32-year-old man suffered an L1 compression fracture following an all-terrain vehicle rollover accident.  He saw a neurosurgeon who placed him in a rigid back brace and prescribed pain medications.  The patient’s fracture appeared to be clinically stable and appeared to be improving.  The Board deemed the long-term risk of developing a kyphotic deformity low in this patient.

On 3/7/2008,  the neurosurgeon performed a kyphoplasty of the spine the patient.  During the kyphoplasty, the vertebral body was too dense to accept the cement.  As a consequence, the cement extruded out of the fracture plans into the epidural space.

The neurosurgeon addressed this complication by performing a posterior laminectomy and decompression of the thecal sac.  The Board stated that the laminectomy procedure subjected the patient to a far greater risk for development of kyphosis than had existed prior to the kyphoplasty.

The Board considered the surgery unwarranted and issued a reprimand.  The neurosurgeon was ordered to complete 10 hours of continuing medical education in the subject of patient selection for spinal surgery.

State: Virginia


Date: November 2017


Specialty: Neurosurgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder, Fracture(s)


Medical Error: Unnecessary or excessive treatment or surgery, Procedural error


Significant Outcome: N/A


Case Rating: 5


Link to Original Case File: Download PDF



Florida – Neurosurgery – Cervical Microdiscectomy At Levels C5/7 And C6/7 Instead Of Levels C4/5 And C5/6



On 11/17/2014, a patient presented to a neurosurgeon for an anterior cervical microdiscectomy for decompression with allograft fusion at cervical levels C4/5 and C5/6.  During the procedure, it was discovered that the initial localization x-ray was misinterpreted and that the neurosurgeon performed the fusion at cervical levels C5/7 and C6/7 instead of cervical levels C4/5 and C5/6.  After the neurosurgeon discovered the error, he proceeded to perform the fusion at the correct cervical levels, C4/5 and C5/6.

The Board judged the neurosurgeons conduct to be below the minimum standard of competence given that he performed the procedure on the wrong site.

The Board ordered that the neurosurgeon pay a fine of $5,000 against his license and pay reimbursement costs of a minimum of $1,859.22 but not to exceed $3,859.22.  The Board also ordered that the neurosurgeon complete five hours of continuing medical education in “Risk Management” and complete a one hour lecture/seminar on wrong site surgeries.

State: Florida


Date: November 2017


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Orthopedic Surgery – Damage To Inferior Vena Cava And Other Complications After Guidewire Improperly Placed In Disk Space



On 12/24/2014, a 59-year-old female was admitted to a medical center for a Microscopic Extraforaminal Lumbar Discectomy of L4-L5.  An orthopedic surgeon was assigned to perform the patient’s procedure.  He began the procedure by utilizing image intensification to use a guidewire for initial placement of dilators in the patient’s spine.

After removal of the guidewire, the orthopedic surgeon noted that he felt the guidewire had gone into the disk space slightly.

After sixty percent of the procedure was completed, the orthopedic surgeon was advised by the anesthesiologist that there was a decrease in the patient’s CO2.  It was subsequently noted that the patient’s blood pressure began to drop.

The orthopedic surgeon then placed an OpSite over the patient’s incision, turned the patient to a supine position, and called for assistance from a vascular surgeon.

On 12/24/2014, after becoming hypotensive and then experiencing pulseless electrical activity during the lumbar discectomy, the patient underwent an exploratory laparotomy with repair of inferior vena cava injury.

During the exploratory laparotomy, after approximately one hour of cardiopulmonary resuscitation and advanced cardiac life support protocol, the patient expired on the operating table.

At all times relevant to this case, the prevailing professional standard of care requires that when dealing with patients such as this one, a physician should place instruments into a patient’s body in a manner to do the least possible harm.

The Board judged the orthopedic surgeons conduct to be below the minimal standard of competence given that he allowed an instrument to pass into the patient’s cavity in such a way that injured underlying structures and by failing to recognize the penetration of the guidewire at the time of placement of the initial dilator, which lead to the injury of the patient’s inferior vena cava.

It was requested that the Board order one or more of the following penalties for the orthopedic surgeon: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: October 2017


Specialty: Orthopedic Surgery


Symptom: N/A


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


Medical Error: Procedural error


Significant Outcome: Death


Case Rating: 4


Link to Original Case File: Download PDF



Florida – Neurosurgery – Laminectomy Performed On The Patient’s L3-L4 Level Instead of L4-L5 Level



In March 2016, a 72-year-old male sought treatment from a neurosurgeon for low back pain.  The neurosurgeon diagnosed the patient with lumbar spondylosis and lumbar spinal stenosis.

Informed consent was obtained from the patient for an L4-L5 laminoforaminotomy for the decompression of the spinal cord and partial medial facetectomy.

On 3/23/2016, the neurosurgeon performed a laminectomy at the patient’s L3-L4 level (wrong site) rather than at the L4-L5 level (correct site).

Approximately three months after the surgery, the patient saw his primary care physician because his back pain had returned.  The patient’s primary care physician obtained an MRI on 7/6/2016.  The MRI results revealed spinal stenosis at the patient’s L4-L5 level and post-operative changes at the L3-L4 level.

After reviewing the patient’s post-surgery MRI, the neurosurgeon realized that she performed the procedure at the L3-L4 level.

It was requested that the Board order one or more of the following penalties for the neurosurgeon: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: August 2017


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Florida – Anesthesiology – Multiple Procedural Errors While Performing Cervical Epidural Steroid Injections



On 4/6/2016, a 69-year-old female with a prior history significant for pulmonary tuberculosis, essential hypertension, paroxysmal supraventricular tachycardia, osteoporosis, menopause, hypothyroidism, arthritis, chronic asthmatic bronchitis, and a former smoker, presented to a medical clinic.

An anesthesiologist initially diagnosed the patient with cervicalgia and cervical radiculopathy due to degenerative chronic cervical spondylosis.  The patient was also hearing and speech impaired and used an interpreter and tablet for communication during all preoperative meetings.

The patient presented to the anesthesiologist in the surgery room for a signed consent of cervical transforaminal epidural steroid injection at right C4 and C5.  The anesthesiologist instead performed a cervical epidural steroid injection (“CESI”) above C6-C7 without obtaining consent from the patient.

The anesthesiologist failed to have an interpreter in the surgery room during the patient’s evaluation and treatment so that he could effectively communicate with her.

The patient was positioned in the prone position on the table and the anesthesiologist administered Versed 2 mg IV and Fentanyl 100 mcg for IV conscious sedation.

The anesthesiologist failed to administer local anesthesia to numb the patient’s skin, while she was awake and alert, prior to injecting the first epidural steroid injection at C5-C6.  The patient, unaware that she was receiving an injection and unable to clearly communicate her discomfort, responded to the initial puncture to her skin by a sudden jumping movement.

The anesthesiologist withdrew the needle and targeted lower interspace, C7-T1, using fluoroscopy.  He used a seventeen gauge Tuohy needle under intermittent fluoroscopic guidance for entry into the epidural space at C7-T1 for the second attempt to perform the CESI.  The anesthesiologist then injected the medication between C4 and C5 neural foramen.

The anesthesiologist documented one or more times prior to the 4/6/2016 procedure that he was performing a TFESI on the right at C4 and C5;  however, he instead performed a cervical interlaminar epidural steroid injection (“ILESI”) at C5-C6, and additionally at C7-T1, without obtaining consent from the patient.  He inappropriately elected to perform a CESI above C6-C7.  The anesthesiologist did not create or maintain fluoroscopic images of his initial attempt to inject at C5-C6.

After the procedure, the patient was taken to the recovery room, where an interpreter and tablet was present for communication.  The patient was no longer able to move her arm to communicate using the tablet and she experienced right upper extremity weakness and some right sided facial numbness.

The patient was transferred out of the medical center as a “Stroke alert” to a hospital, where she received a CAT or MRI scan, and again transferred to another hospital which did not have a neurosurgeon on staff.

After the CESI, the patient was diagnosed with iatrogenic cervical nerve root injury.

It was requested that the Board order one or more of the following penalties for the anesthesiologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: August 2017


Specialty: Anesthesiology


Symptom: Weakness/Fatigue, Numbness


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


Medical Error: Wrong site procedure, Ethics violation, Failure of communication with patient or patient relations, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Neurosurgery – Laminotomy And Foraminotomy Performed At One Level Lower Than Intended



On 12/9/2015, a patient presented to a neurosurgeon at the Laser Spine Institute with complaints of lower back pain and bilateral lower leg pain.

The neurosurgeon reviewed a previous MRI result for the patient which indicated that the patient had a lumbarized sacrum, foraminal stenosis at L5-S1 bilaterally, and L4-5 facet hypertrophy.

The neurosurgeon also reviewed previous nerve root block results, which indicated 20% relief at L5 and 80% relief when performed at L4-5.

The neurosurgeon recommended that the patient undergo a right laminotomy and foraminotomy at the L4-5 level.

On 12/11/2015, the patient returned for the recommended procedure.  The neurosurgeon performed a right laminotomy and foraminotomy on the patient at what he thought was the L4-5 previously identified at the 12/9/2015 visit.

The neurosurgeon relied on intraoperative imaging to find the operative level.

Due to the patient’s vertebral anatomy, on 12/11/2015, the neurosurgeon actually performed the procedure one level below the level he previously identified on the 12/9/2015 visit.  The level the neurosurgeon performed the procedure was the incorrect site and was not the site the neurosurgeon identified as the operative level at the 12/9/2015 visit.

On 2/24/2016, the neurosurgeon performed a second right laminotomy and foraminotomy on the patient, this time at the correct site, which was one level above the surgery he performed on 12/11/2015, and the same level he identified at the 12/9/2015 visit.

It was requested that the Board order one or more of the following penalties for the neurosurgeon: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: July 2017


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain, Extremity Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Wrong site procedure


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



California – Radiology – Epidural Injection With Subsequent Lower Extremity Pain And Sensory And Motor Function Loss



On 1/15/2010, a 61-year-old female underwent an epidural injection.  Following the procedure, she complained of sharp pain in the lower extremities, followed by sensory and motor function loss below the T10 and T11 level.  The patient was transferred by ambulance to the emergency department.

A thoracic and lumbar MRI was performed and interpreted by a radiologist.  The final report for the lumbar spine states “Mild desiccation and degenerative changes of the disc but no disc bulge or herniation is noted.”  His final report of the thoracic spine demonstrates “normal MRI of the thoracic spine…A repeat study of the thoracolumbar spine is recommended without contrast infusion in both projections to better evaluate this area as this is on the edge of the study on the current images both lumbar and thoracic is not well delineated.”  Although the images were suboptimal, the epidural hematoma of the lower thoracic spine was evident in the axial images.

On 1/19/2010, a repeat MRI was performed.  The radiologist interpreted the MRI stating there is “abnormal signal focus demonstrated in the spinal canal from approximately the T10-T11 disc space inferiorly through the T12-L1 disc space located mostly in the posterior and posterolateral aspect of the spinal canal displacing the cords slightly anteriorly and causing a slight mass effect on the cord and subarachnoid sac.  This is consistent with a subdural or epidural hematoma.”

The Board judged the radiologist’s conduct as having fallen below the standard of care given failure to observe and document all pertinent findings on diagnostic imaging studies, failure to discuss findings requiring urgent treatment with the referring physician, failure to diagnose the abnormality found on MRI, and failure to document his discussion with the referring physician regarding the abnormality on MRI.

A public reprimand was issued against the radiologist.

State: California


Date: June 2017


Specialty: Radiology, Emergency Medicine


Symptom: Extremity Pain, Numbness, Weakness/Fatigue


Diagnosis: Spinal Injury Or Disorder


Medical Error: False negative, Failure of communication with other providers, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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