Found 63 Results Sorted by Case Date
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Florida – Neurosurgery – Wrong Site Procedure When Performing Surgery On A Subdural Hematoma



On 11/6/2016, a 61-year-old female presented to the emergency department, suffering from confusion and weakness after a fall.  A CT scan revealed that the patient had a large, left-sided subdural hematoma.

That same day, a neurosurgeon was asked to evaluate the patient.  The neurosurgeon correctly documented that the patient was suffering from a left-sided subdural hematoma.  The neurosurgeon further documented his intention to remove a blood clot from the left side of the patient’s subdural space.

Shortly thereafter, the patient was brought to the operating room and preparations were begun for a left-sided craniotomy.  However, at some point during the preparation process, the patient’s head was turned and the neurosurgeon began to operate on the right side.

After the neurosurgeon made an incision through the skin, he removed a bone flap and punctured the dura mater on the right side of the patient’s brain.  The neurosurgeon realized that he was operating on the incorrect side.  The neurosurgeon closed the operating site and proceeded to perform the correct procedure.

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: December 2017


Specialty: Neurosurgery


Symptom: Confusion, Weakness/Fatigue


Diagnosis: Intracranial Hemorrhage, Trauma Injury


Medical Error: Wrong site procedure


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 – 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 – 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



Arizona – Neurosurgery – Identifying A Dural Arteriovenous Fistula In A Cerebral Angiogram



The Board received notification of a malpractice settlement regarding the care and treatment of a 57-year-old woman.

The suit alleged misdiagnosis of an arteriovenous fistula in the left transverse sinus of the brain and unnecessary performance of procedures.  A Medical Consultant who reviewed the neurosurgeon’s care asserted that the neurosurgeon failed to correctly identify a dural arteriovenous fistula on a diagnostic cerebral angiogram with subsequent unnecessary performance of procedures.

The neurosurgeon admitted that he was unable to comply with the terms of the probationary agreement due to his absence from the country and current financial situation.

The Board ordered that he immediately surrender his license.

State: Arizona


Date: March 2017


Specialty: Neurosurgery


Symptom: N/A


Diagnosis: Neurological Disease


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Neurosurgery – Misplaced Pedicle Screws



A 55-year-old woman with long-standing lower back pain, Patient A, was diagnosed with slipping vertebral bones that resulted in lumbar stenosis and foraminal stenosis.

On 6/26/2014, a neurosurgeon performed lumbar fusion surgery on Patient A.  Patient A’s post-operative course was marked by considerable pain and slow recovery.  Patient A was referred to an orthopedic surgeon at another hospital when her pain did not diminish as expected.  Radiologic images were interpreted as showing misplaced pedicle screws from the lumbar fusion surgery performed by the neurosurgeon.

On 10/22/2014, Patient A underwent a repeat fusion operation with replacement screws.  The operative report notes detailed screw misplacement from the initial surgery.  Patient A underwent a third surgery on 11/4/2014, because of ongoing pain, after which she made improvement.

Patient B was a 19-year-old man with chronic low back and leg pain caused by a collapsed disc.  On 2/13/2014, the neurosurgeon performed lumbar fusion surgery on Patient B.  Patient B’s post-operative course was marked by some relief, but he experienced new pain in his left leg.

Patient B was also referred to the orthopedic surgeon at the other hospital.  Patient B underwent a repeat fusion operation with replacement screws.  Radiologic images and operative report notes documented misplaced pedicle screws from the lumbar fusion surgery performed by the neurosurgeon.

The Commission stipulated the neurosurgeon reimburse costs to the Commission, complete fifty hours of continuing education covering the subject of spine surgeries, including the interpretation of imaging studies of pedicle screw replacement, attend two spine conferences, and complete a total of one hundred proctored spine instrumentation procedures with Commission approved surgeons.

State: Washington


Date: February 2017


Specialty: Neurosurgery, Orthopedic Surgery


Symptom: Back Pain


Diagnosis: Spinal Injury Or Disorder


Medical Error: Procedural error


Significant Outcome: N/A


Case Rating: 1


Link to Original Case File: Download PDF



Washington – Neurology – Neuromonitoring During Decompression Surgery With iO-Flex



On 8/15/2012, a neurologist was the physician in charge of supervising the intraoperative neuromonitoring aspect of a patient’s spinal decompression surgery.  The neurologist was not present in the operating room during the patient’s surgery.  He was at his off-site office supervising the neuromonitoring technician who was present in the operating room during the patient’s surgery.  The neurologist was remotely reviewing data from the patient’s surgery on his desktop and laptop in real-time while an orthopedic surgeon was performing the surgery.

In addition to monitoring the patient’s surgery, the neurologist was also simultaneously acting as a supervisor for the intraoperative monitoring of two other patients.  He was seeing patients in his office in addition to neuromonitoring.

Prior to the patient’s surgery, there was a lack of clear communication about the nature of the case and the use of a new device.  The neurologist understood the operation to be a routine L4/L5 hemilaminectomy as opposed to an operation with a new and unproven device with significant risk of complication.

During the patient’s surgery, the orthopedic surgeon inserted the newly marketed device, the iO-Flex, a micro-blade shaver, into the patient’s back.  During the surgery, on two separate occasions, there was a significant drop in the patient’s nerve signals.  The signals never returned to baseline but the surgery continued.  The neuromonitoring technician informed the neurologist of the signal changes, and documented she informed the surgeon of the changes.  The neurologist did not independently communicate with the surgeon or the neuromonitoring technician.  The neurologist was not in the operating room and had no awareness of what the surgeon was doing or the use of the iO-flex device.  The patient’s cauda equina (bundle of spinal nerves and spinal nerve roots) was damaged.

It took over one month for the neurologist to finalize his report relating to the surgery.  The neurologist’s report, dating 9/14/2012, stated that the patient suffered spinal cord damage, which is inaccurate as there is no spinal cord where the cauda equina is located.  The neurologist’s report is inaccurate when he wrote, “there is no nerve root injury” when the patient actually did suffer severe nerve root damage.  The patient suffered damage to his cauda equina that required additional surgery and resulted in ongoing neurological deficits.

Communication between the remote monitor and the neuromonitoring technician and surgeon is critical to the neuromonitoring process.  The pathways of communication were not mutually understood and did not work as a result.  Communication between the neurologist, the neuromonitoring technician, and the surgeon was less than satisfactory.

The Commission stipulated the neurologist reimburse costs to the Commission, complete a continuing education course on ethics, complete a continuing education course on communication, and write and submit a paper of at least 1000 words on what he learned from the courses and how information he learned applies to this case.

State: Washington


Date: January 2017


Specialty: Neurology, Neurosurgery, Orthopedic Surgery


Symptom: N/A


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


Medical Error: Failure of communication with other providers


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 3


Link to Original Case File: Download PDF



Washington – Orthopedic Surgery – iO-Flex Use For Spinal Decompression



On 7/24/2012, a patient saw an orthopedic surgeon for a preoperative appointment concerning the decision for unilateral decompression surgery at L4-5 secondary to chronic lower back pain radiating to the right lower extremity with numbness and tingling.  The orthopedic surgeon failed to document in his preoperative report his intention to use the iO-flex (minimally invasive micro-blade shaver), a newly-marketed surgical device, during the patient’s upcoming surgery.  The orthopedic surgeon did not disclose to the patient that he had never used this device before.  Specifically, the orthopedic surgeon did not obtain the patient’s informed consent to use the iO-flex.

On 8/9/2012, the patient returned to the orthopedic surgeon’s clinic presenting with a sudden onset of back pain radiating to the left lower extremity.  Magnetic resonance imaging (MRI) revealed a new large disc herniation at L4-5.  This newly discovered injury caused the original surgical plan to change, which the orthopedic surgeon failed to document in his preoperative report and failed to tell the patient.

On 8/15/2015, the orthopedic surgeon began the patient’s decompression with the iO-flex and the progress was being observed by a remote neuromonitoring physician and an on-site neuromonitoring technician.  The neuromonitoring technician informed the orthopedic surgeon that there was a decrease in some of the patient’s sensory nerve signals.  In response, the orthopedic surgeon removed all of the iO-Flex tools and waited for improvement.

While waiting for improvement, there was a lack of clear communication between the orthopedic surgeon, the neuromonitoring physician, and the neuromonitoring technician about a drop in neuromonitoring function.  The orthopedic surgeon had a duty to make sure the information received from the neuromonitoring physician and the neuromonitoring technician was correct.  The changes in function should have been noted in the orthopedic surgeon’s operative report, but were not included.  Due to this omission, the orthopedic surgeon’s report incorrectly implied there were no complications.  When the orthopedic surgeon inserted the iO-flex micro-blade shaver into the patient’s spine and performed about sixty reciprocations for decompression, the orthopedic surgeon unknowingly damaged the patient’s cauda equina (bundle of spinal nerves and spinal nerve roots).

On 8/16/2012, the orthopedic surgeon examined the patient in the recovery room.  The patient had weakness and numbness in both feet.  On 8/17/2012, based on the patient’s presentation of weakness in both feet and a newly experienced loss of bladder control, an MRI was ordered and the orthopedic surgeon recommended exploratory surgery.

On 8/18/2012, the orthopedic surgeon performed the exploratory surgery.  The exploratory surgery revealed cauda equina damage and a tear in the patient’s dura (a watertight sac of tissue that covers the spinal cord and spinal nerves).  Given the seriousness of the neurological complications (weakness, numbness, bladder dysfunction), the exploratory operation should have been completed when those symptoms were first noted, not two days later.

The orthopedic surgeon treated the patient’s dural tear with a sealant. The orthopedic surgeon failed to document fluid leaking in the patient’s spine in his post-operative report and there was no documentation of an appearance of fluid collection in the patient’s exploratory MRI report.  The orthopedic surgeon should have documented these complications.

The Commission stipulated the orthopedic surgeon reimburse costs to the Commission, complete a continuing education course on ethics, complete a continuing education course on medical record keeping, and write and submit a paper of at least 1000 words on what he learned from the courses and how information he learned applies to this case.

State: Washington


Date: January 2017


Specialty: Orthopedic Surgery, Neurosurgery


Symptom: Back Pain, Numbness, Extremity Pain


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


Medical Error: Procedural error, Delay in proper treatment, Ethics violation, Failure of communication with other providers, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



North Carolina – Neurosurgery – No Extremity Movement After Spinal Cord Decompression



On 06/12/2014, the Board was notified of a professional liability payment made on behalf of a neurosurgeon.

In February 2011, a 40-year-old male presented to a neurosurgeon with neck pain and left arm weakness. An MRI showed compression of the spinal cord from the C4 to the C6 vertebral body.

On 02/16/2011, the neurosurgeon performed spinal surgery on the patient. After the operation, the patient was taken to the recovery room and was found to have no extremity movement except for a “flicker” in his upper extremities.

On 02/17/2011, a CT scan showed persistent cervical spinal cord compression. The neurosurgeon continued to monitor the patient.

On 02/24/2011, an MRI showed spinal cord damage at the operative site.

On 03/02/2011, the patient was transferred to a spinal cord rehabilitation center in Georgia, where he underwent another operative procedure and rehabilitation. The patient recovered function of his arms and legs, but has some remaining neurological deficits.

The Board had the neurosurgeon’s treatment of the patient reviewed by an independent medical expert who felt the neurosurgeon’s care of the patient was below the accepted minimum standard of care.

Specifically, this expert felt the neurosurgeon’s neurologic monitoring of the patient during surgery was inadequate, and the post-operative care should have been different in that an MRI should have been performed sooner and surgical intervention undertaken earlier to address the patient’s spinal cord compression and new post-operative neurologic deficits.

This medical expert also felt that the neurosurgeon’s medical record documentation was inadequate.

The Board acknowledged the neurosurgeon had his care reviewed by another independent medical expert who found that the neurosurgeon’s care of the patient was within the accepted standard of care. This independent medical expert felt the neurosurgeon’s treatment approach was appropriate and that a second surgical intervention was not warranted while the patient was under the neurosurgeon’s care based on the CT scan and MRI findings and the patient’s clinical course.

The Board noted that the neurosurgeon was in the process of undergoing a voluntary and independent preceptorship with the UNC Department of Neurosurgery (“UNC Preceptorship”).

The UNC Preceptorship was expected to last a minimum of six months and involved continuing medical education via chart review, surgical observation, and further training in medical record coding and documentation. The Board noted that the neurosurgeon agreed to complete the UNC Preceptorship and provide proof of completion to the Board.

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: December 2016


Specialty: Neurosurgery


Symptom: Head/Neck Pain, Weakness/Fatigue


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


Medical Error: Procedural error, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



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