healthcare

Improper performance of pain management procedure 

Presentation 

On April 14, a 50-year-old man with a long history of chronic pain, spinal  injuries and procedures, depression, and obesity, came to see Anesthesiologist  A for pain management. The patient sought treatment for radiating neck and  low back pain and migraine headaches. The patient’s medications included  methadone, ibuprofen, paroxetine, tizanidine, and hydrocodone/acetaminophen  (7.5/325).  

An MRI of the patient’s lumbar spine revealed degenerative disc disease at the  L3-4 and L4-5 vertebrae with spinal stenosis at L4-5. A cervical spine MRI  showed a C4-5 fusion but was otherwise normal.  

Physician action 

On April 22, Anesthesiologist A performed a bilateral L4-5 epidural steroid  injection (ESI). The patient did not return for a follow-up appointment one  month later.  

However, the patient did return to the physician’s office on July 1. He reported  mild pain relief for approximately ten days following the ESI. The patient’s  motor strength was normal, 5/5 throughout. 

Three weeks later during the next follow-up appointment, Anesthesiologist A  and the patient discussed an epiduroscopy and Percutaneous Ablation and  Curettage and Inferior Foraminotomy (PACIF) with a plan to refer to  neurosurgery if the patient saw no relief. The patient agreed to the procedures. 

On August 16, the patient was admitted for the epiduroscopy and PACIF at L5  on the right side. During the procedure, Anesthesiologist A encountered  epidural space adhesions and could not obtain access to the neural foramen of 

L4-5 on the right. Due to minor but persistent bleeding, Anesthesiologist A  decided to terminate the procedure and injected 5 ml of a hemostatic matrix in  the area of bleeding and retracted the scope. 

A neurosurgery consultation was obtained. Neurosurgeon A noted no  neurological deficits on examination and indicated no need for neurosurgical  intervention.  

Anesthesiologist A saw the patient the next day and noted weakness of the  right leg. An MRI showed postoperative changes at L4-5 with an epidural  collection resulting in mild stenosis starting at L4-5 and extending to S2,  consistent with evolving traumatic epidural hemorrhage. The patient was  discharged to home. 

On August 21 during a follow-up telephone call, the patient reported inability to  raise his big toe and foot on the right side. Anesthesiologist A referred the  patient to Neurosurgeon B. 

Neurosurgeon B performed electromyography and nerve conduction velocity  tests on August 26. The patient had significant pain and weakness and  expressed concern for injury in the past 10 days.  

The next day, the patient underwent decompression and laminectomy of L4-5  and L5-S1 with removal of the hemostatic matrix and an epidural hematoma.  The patient was discharged the next day with an ankle foot orthotic. 

Following physical therapy, the patient’s foot drop resolved; however, there  may be elements of secondary gain in the future.