36C10X19Q0200-015.pdf

Patient: Case Identifier:

Medical Advisory Opinion Report

VISN: Case ID: 3075510

Case Identifier:

Facility: Station #:

Patient Name: SSN (4):

Incident Date:

Date(s) Range of the Episode of Care:

Practitioner (if applicable):

Practitioner’s Specialty (if applicable): Neurosurgery

Practitioner’s Credential (if applicable): MD

Attorney Name:

Requested Reviewer Specialty/Credential: Neurosurgery

Review type: MAO

Post-operative (2nd operation):

On – , the patient was seen by physical therapy. He had little functional use of his upper and lower extremities. He had poor grip strength and decreased functional grasp. Physical therapy notes from , indicated that the patient had little sensation or movement of his lower extremities and little movement of his hands. The patient was sporadically confused as well.

On , the attending neurosurgeon’s note indicated that the patient's neurological level of function had not significantly improved despite the anterior cervical discectomy fusion (ACDF) C6-C7 surgery of

. The patient was paraplegic and had significant weakness in his upper extremities - +2/5 intrinsic hand and grip strength. The patient had a sensory level at T2. Plans were initiated for transfer to the spinal cord injury rehabilitation center in . Continued supportive care was advised.

2016 (3rd operation):

Follow-up imaging was obtained that showed persistent cord compression, and instability of the cervicothoracic junction. Instability of the cervicothoracic junction was deemed to be present.

Additional surgery was recommended. The patient was returned to the OR for a third procedure. A C7 laminectomy and extension of his instrumentation to T2 was performed during this procedure. Again, intra-operative fluoroscopy and neuronavigation were used to facilitate the surgery. Compression of the right side of the spinal cord by the C7 lamina and compression of the C7 nerve root was noted at the time of surgery. Post-operatively, the patient remained clinically stable. Unfortunately, the additional surgery did not improve his condition. His neurological condition remained unchanged despite the 2nd and 3rd operations. Because of his infirmity, he developed a sacral decubitus. Referral to an acute spinal cord injury rehabilitation center was planned. The surgical drain that was placed in the wound at the time of the surgery was removed on , without incident.

Post-operative (3rd operation):

The patient remained to be clinical stable; however, his neurological condition was unchanged. There was 0/5 strength in the lower extremities, 2/5 strength of hand grip and intrinsic hand strength, 4-4+/5 strength in the biceps, 3/5 strength in the left triceps, and 4/5 strength in the rest of the upper extremities. Deep vein thrombosis (DVT) prophylaxis, aggressive bowel regimen, pain control, and psychiatric support were utilized to support the patient and to prepare him for eventual transfer to a spinal cord rehabilitation center. The patient was transferred to the on .

Discharge medications upon transfer included: atorvastatin, bicalutamide, cyclobenzaprine 5 t.i.d. for muscle spasm, gabapentin 900 mg t.i.d., heparin subcutaneously 5000 every 8 hours, insulin aspartate 100 units per mL b.i.d., labetalol, insulin glargine 10 units with breakfast, Eligard, levothyroxine, losartan, metoprolol, morphine sulfate for moderate-to-severe pain, omeprazole, Zofran p.r.n. for nausea, oxycodone 5 mg every 6 hours p.r.n. for pain, sertraline, trazodone, and aspirin 81 mg.

Spinal Cord Injury Unit:

The patient was transferred to , on to . Treatment modalities at the facility included: rehabilitation, frequent turning in bed (to prevent progression of current sacral ulcer), staple removal, use of sliding insulin scale for his diabetes management, and psychological support (the patient was having difficulty coping with his new neurologic deficits). Sertraline and trazodone were prescribed by the consulting VA psychiatrist.

The discharge summary from the rehabilitation center includes the following diagnoses:

1. C6 myelopathy, American Spinal Injury Association Scale C, new injury;

2. neurogenic bowel and bladder;

3. sexual dysfunction secondary to prostate cancer;

4. hypertension;

5. obstructive sleep apnea;

6. hypothyroidism, on replacement therapy;

mechanical injury to his lower cervical spine. It was purely speculative to think that the use of a cervical collar would have prevented this clinical scenario. In the reviewer’s opinion, he should have used a collar particularly when out of bed or ambulatory. These devices are uncomfortable for patients and often there is no way of knowing whether patients are complying with the use of a collar, or not.

Whether he was instructed to wear a collar, or not, was not found documented in the records.

Standard of care:

In the reviewer’s opinion, the standard of care was met throughout this entire case. This was an unfortunate series of events that occurred subsequent to this patient’s initial surgery. The rationale for proceeding with surgery, the diagnostic tests and techniques that were used, and the planning and technical performance of each surgery met the usual standards of care. The C6, C7 disc herniation and the decision to proceeding with an ACDF seems logical and made sense. The decision and rationale of performing another operation posteriorly to decompress and stabilize the cervicothoracic junction to T2 were done in an attempt to optimize the outcome of his spinal cord injury. Unfortunately, once this patient presented to the ER for his second surgical procedure (ACDF at C6-C7), "the die was cast." The patient had sustained a significant spinal cord injury as a result of the disk herniation and spinal cord contusion. The subsequent 2nd and 3rd surgical procedures were attempts of optimizing the chance for neurological recovery in an otherwise fragile patient. The 2nd and 3rd operation did not seem to worsen, or significantly improve his neurological condition.

Overall, in the reviewer’s opinion, each provider involved in this case met the standard of care. The treatments and diagnostic tests were appropriate and handled in a timely fashion. Any reasonable practitioner in North America, and worldwide, would have handled the case in a similar fashion, in the reviewer’s opinion.

Regarding the issue of whether this case should be settled or defended: This is a legal judgment call, in the reviewer’s opinion. I do not think that this man was injured by the surgeons involved. This patient would have to assume some responsibility for his care. If his doctor recommended that he stay in the hospital after the first operation, the reviewer was perplexed as to why he did not want to do so. The patient had additional problems with seizures and falling, and it would seem that the safest place for the patient would be in the hospital or spinal rehabilitation unit. It sounds as though the patient was not terribly attentive to his overall medical care. Nevertheless, if this case were to go to trial, a sympathetic jury could potentially see this neurologically impaired patient in a wheelchair and feel compassionate for his overall plight. Despite how the jury is instructed by the court, the jury’s decision could be based on what they are seeing, rather than the objective facts of the case.

In the reviewer’s professional opinion, there was no wrong doing based on the part of the practitioners.

Within a reasonable degree of medical certainty, the practitioners involved, and , met the acceptable standard of care as it would pertain in with their management of this patient.

In general, patients with significant comorbidity, including diabetes, cardiovascular disease, and a significant degree of spinal cord compression (all were present in this patient) were at increased risk of neurological complications intra-operative and peri-operatively. A patient’s clinical outcome is not always under the control of their physician particularly once the patient has been discharged to home.

This patient insisted on going home after the first operation and should assume some of the responsibility regarding his outcome.

Unfortunately, this man sustained a significant spinal cord injury due to the fall at home. He was unable to care for himself. He required care rendered by his relatives and various medical care professionals. Although, this was an unfortunate outcome, the reviewer does believe that the patient’s outcome was not caused by the physicians who were trying to mitigate his problems. This patient was left with a condition that left him with a complicated life care plan.

Reviewed by:

Specialty: Neurosurgery Date: