Patient Suffers Neuromuscular Deficits Following Spinal Injections; Poor Coordination of Care Results in Paralysis and Malpractice Lawsuit

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DrSpine

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Someone sent me this after seeing it on the MedPro Malpractice page.

Kind of curious, all other stuff aside, it seems like the patient while having a large herniated disc causing thecal sac compression - did not initially have red flag symptoms at that time until after the SIJ Blocks? And if that is the case, this automatically means you if you fail to send to a surgeon for decompression, you're liable for eventual paralysis/cauda equina symptoms should it happen in the weeks / months / years ahead?

I feel like most patients we see have disc protrusion/herniations causing effacement of the thecal sac or mild thecal sac compression. If no bowel/bladder dysfunction or red flag issues, many will perform an ESI. Unless I am misunderstanding that part of the story (ignoring the rest about communication issues and discharge/failure to examine), isn't this a bit ridiculous?

Let me know what the rest of you think on the matter.

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Many balls were dropped here. Patient should have been sent emergently for MRI after a few hours of not being able to walk. You don’t send someone home who has basically paralysis. I would have sent them sooner after an SIJ injection.. why would the patient have weakness after SIJ injection? Tons of mistakes IMHO. This case is an attorney’s wet dream. And that’s just the first few hours.. smdh
 
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Laryngospasm said:
Many balls were dropped here. Patient should have been sent emergently for MRI after a few hours of not being able to walk. You don’t send someone home who has basically paralysis. I would have sent them sooner after an SIJ injection.. why would the patient have weakness after SIJ injection? Tons of mistakes IMHO. This case is an attorney’s wet dream. And that’s just the first few hours.. smdh
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Right and I get all that. Aftermath was definitely fumbled. I assume they had an MRI before the epidural and SIJ in the last 2 years, Not sure why L2-3 herniation was brought as a reason though for “being at fault” for not sending to NS earlier in absence of red flags. Unless I am misunderstanding that and my brain is fried tonight after a long day :lol:
 
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From Med mal perspective, who do you need to document you sent to neurosurgery? Anyone with neurologic symptoms? That would be almost everyone. I have often wondered about this. I usually recommend ns to anyone with any noticeable strength deficit on my physical exam, or any really intense subjective neurologic changes...but a lot of people say “hell no I’ll never go to a surgeon.” I really push it only occasionally with the usual red flags, acute bowel/bladder, saddle anesthesia, serious/acute strength deficits, etc.
Anyone do this significantly differently?
 
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Wow I’ve had similar scenarios several times over my 12 years after anesthetic from the SIJ injection leaked through the anterior capsule covering the LS plexus. One patient had such a dramatic paretic leg that we admitted her. I chalked it up to joint capsule leakage and malingering. She was fine the next morning. I never would’ve thought she had a separate massive disc herniation during my injection. That’s just bad luck! Also had this happen to a lady a few months ago. I called and spoke with her and her daughter that night and reassured them. She was fine the next day and has been pain free since. This case is just a freak coincidence
 
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Whenever I see a decent-sized disc herniation and central canal stenosis I give the patient a standard “red flags for cauda equina” talk and document the discussion in the chart. Consider the surgeon who sees the patient and does not urgently schedule them for decompression - that’s how they cover themselves if an asymptomatic patient suddenly develops a problem.
 
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clubdeac said:
Wow I’ve had similar scenarios several times over my 12 years after anesthetic from the SIJ injection leaked through the anterior capsule covering the LS plexus. One patient had such a dramatic paretic leg that we admitted her. I chalked it up to joint capsule leakage and malingering. She was fine the next morning. I never would’ve thought she had a separate massive disc herniation during my injection. That’s just bad luck! Also had this happen to a lady a few months ago. I called and spoke with her and her daughter that night and reassured them. She was fine the next day and has been pain free since. This case is just a freak coincidence
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How much local are you injecting?
 
I used Marcaine 0.5% 0.7 ml plus Depo 40. Never had motor weakness occur. Patients had pain relief. OTOH I have seen procedure notes with 5 ml of local...
 
I’ve never seen weakness either. I use 2cc plus 40depo.
 
I use 0.5 - 1.0 cc ropivacaine and 40 Depo. Never had weakness.

Had a young attending in fellowship using 5 - 6 cc of injectate. Pt had anesthesia of the leg with gait dysfxn.
 
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clubdeac said:
Wow I’ve had similar scenarios several times over my 12 years after anesthetic from the SIJ injection leaked through the anterior capsule covering the LS plexus. One patient had such a dramatic paretic leg that we admitted her. I chalked it up to joint capsule leakage and malingering. She was fine the next morning. I never would’ve thought she had a separate massive disc herniation during my injection. That’s just bad luck! Also had this happen to a lady a few months ago. I called and spoke with her and her daughter that night and reassured them. She was fine the next day and has been pain free since. This case is just a freak coincidence
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I disagree. Bilateral leg numbness and weakness after bilateral SI joint injections is not expected and should not be viewed as a "normal side effect". Sure, you might have leakage of local anesthetic unilaterally to cause these symptoms unilaterally, but bilateral full paralysis after SI joint injection? Something is clearly awry here. If the patient walked into the ASC for SI joint injections, they should be able to walk out. Huge red flags were missed here.
 
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In fellowship we would give 5ml bupi .25% lumbar interlaminar. They weren’t weak ever. So I don’t think a small amount of local leaking into the epidural space from a SI joint injection should cause any weakness.
 
no reason to inject the SIJ with more than 1ml. use some extra for ligaments if you desire, but no reason to expand the joint capsule
 
I personally have never had a single patient getting SI injection have demonstrable leg weakness after injection.

S1, yes. not SI.
 
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Ducttape said:
I personally have never had a single patient getting SI injection have demonstrable leg weakness after injection.

S1, yes. not SI.
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I have. 2 in 7 years. I presume local either extravasated inferior to sciatic or anterior to ls plexus. Unilateral though. And I usually use 1.5-2cc 2% lido, intra articular then pull out and get dorsal ligaments.
 
Patient had an L2 L3 herniation with stenosis. If the patient was weak because of local anesthetic from the sacroiliac joint injection, It should have been in a sciatic distribution. This would not have been consistent with weakness due to L23 pathology. If Central, you would think that you would also have problems with L3, L4. Would think this could’ve been teased out with a physical exam.
 
when you get weakness after an SIJ, you are probably blocking the sciatic nerve and are way off track.

i have never seen weakness after an SIJ injection, and i probably am somewhere around 2000 of them.

i have no idea why this doc decided that an SIJ injection was the right move, given the severe L2-3 stenosis. i would need to actually see the pre and post MRI images at L2-3 to make a better call about exactly what happened
 
1. in what world would an caudal injection help L23 stenosis...

2. amazing to think that an ASC would allow a patient to "stay" at least 3 1/2 hours after an SI injection before re-contacting the physician.

and until 10pm, almost 7 hours after the physician left?



7 hours after my patients leave, they are calling to book their next procedure...
 
Ducttape said:
1. in what world would an caudal injection help L23 stenosis...

2. amazing to think that an ASC would allow a patient to "stay" at least 3 1/2 hours after an SI injection before re-contacting the physician.

and until 10pm, almost 7 hours after the physician left?



7 hours after my patients leave, they are calling to book their next procedure...
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Caudal with 160mg depo and 15cc volume?
 
Lots of errors but the initial error was in the pain doc not recognizing bilateral lower extremity numbness and weakness from sacroiliac injections is profoundly rare, and not looking for another cause. The most likely cause: a patient with severe congenital stenosis at L2 placed in the prone position and herniating a disc while on the table or in transfer to or from the table. Other major screwups- discharging a newly paralyzed patient to home, failure of the team to obtain appropriate imaging (CT or CT myelogram at the initial hospital) or sedating for the MRI, neurology failing to recognize the severity of the situation, etc.
 
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Interesting study regarding surgical timing referenced during the discovery phase.

J Orthop. 2018 Mar; 15(1): 210–215.
Published online 2018 Feb 28. doi: 10.1016/j.jor.2018.01.020

Influence of timing of surgery on Cauda equina syndrome: Outcomes at a national spinal centre​

Gavin Heyes,⁎ Morgan Jones, Eugene Verzin, Greg McLorinan, Nagy Darwish, and Niall Eames

Abstract​

Purpose​

There is no doubt that the best outcome achieved in Cauda equina syndrome (CES) involves surgical decompression. The controversy regarding outcome lies with timing of surgery. This study reports outcomes on a large population based series. Timing of surgery, Cauda Equina syndrome classification based on British Association of Spine Surgeons (BASS) guidelines and co-morbid illness will be assessed to evaluate influence on outcome.

Materials and methods​

A retrospective review of all patients surgically decompressed for CES between 01/01/2008 to 01/08/2014 was conducted. Patients with ongoing symptoms were followed up for a minimum of 2 years. Cauda Equina Syndrome (CES) was classified according to the BASS criteria: CES suspicious (CESS), incomplete (CESI) and painless urinary retention (CESR). Time and symptom resolution were assessed.

Results​

A total of 136 patients were treated for CES; 69 CESR, 22 CESI and 45 CESS. There was no statistical difference in age, sex, smoking status and alcohol status with regards to timing of surgery. No correlation between increasing co-morbidity score and poor outcome was demonstrated in any subgroup
All CESR/I patients demonstrated some improvement in bowel and bladder dysfunction post-operatively. No significant difference in improved autonomic dysfunction was demonstrated in relation to timing of surgery. CES subclassification may predict outcome of non-autonomic symptoms. Statistically better outcomes were found in CESS groups with regards to post-operative lower back pain (P 0.049) and saddle paraesthesia (P 0.02).

Conclusion​

Surgical Decompression for CES is an effective treatment that significantly improves patient symptoms including bowel and bladder dysfunction Early surgical decompression <24 h from symptom onset does not appear to significantly improve resolution of bowel or bladder dysfunction.
 
No_Pain_No_Gain said:
I disagree. Bilateral leg numbness and weakness after bilateral SI joint injections is not expected and should not be viewed as a "normal side effect". Sure, you might have leakage of local anesthetic unilaterally to cause these symptoms unilaterally, but bilateral full paralysis after SI joint injection? Something is clearly awry here. If the patient walked into the ASC for SI joint injections, they should be able to walk out. Huge red flags were missed here.
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Yeah I agree bilateral leg pain would raise multiple red flags. It was unilateral on the side I did the injection and now that I think about it's only happened twice in my career. Still think in my situation it was from anterior capsular spread which can happen with ~2.5ml of injectate as both patients had text book arthrograms
 
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