This case involves a sixty-seven-year-old female patient with a past medical history significant for osteoarthritis, rheumatoid arthritis and chronic back pain. The patient presented to the hospital complaining of a three month history of severe neck and upper back pain. The patient was diagnosed with a displacement of a cervical intervertebral disc and was admitted to the neurosurgery service after a workup revealed cervical spinal stenosis, cervical myelomalacia and cervical spondylosis. The patient underwent an anterior discectomy and fusion at C5/C6 and C6/C7 with SSEP and MEP monitoring in place throughout the operative procedure. The operative notes described the removal of a significant amount of osteophytes and the use of plates and screws to secure the fusion. The procedure was conducted without incident and the patient recovered well. A stage two spinal stabilization procedure was scheduled for the following week. The second procedure was conducted however this time MEP monitoring was not employed. The patient awoke from surgery with a paralyzed right upper extremity. A CT scan was performed which revealed no neurolaminal vertebral, foraminal, or central canal encroachment from metallic hardware. Electromyography (EMG) and nerve conduction studies were performed. Following the investigation the treating neurosurgeons came to the conclusion that there was electrophysiologic evidence of bilateral brachial plexopathies with widespread active denervation in all tested muscles innervated from C5 to T1. The patient was diagnosed with bilateral brachial plexopathy with the right side being injured to a much greater extent than the left. The patient was referred to a rehabilitation facility for further treatment but made minimal progress. The patient was left with little function in her upper extremity and saw no improvement with further medical treatments.
Question(s) For Expert Witness
1. Are the issues faced by this patient recognized complications of this procedure?
2. Should the treating neurosurgeon have used MEP monitoring during the second procedure?
Expert Witness Response E-001705
I would have expected the paralysis after the anterior approach, not the second stage posterior fusion procedure. Posteriorly, a surgeon is working primarily on bone and is away from the spinal cord and nowhere near the brachial plexus. This is a very unusual occurrence and further review of the medical and surgical notes is warranted to find out exactly what went wrong for this patient. With regards to the spinal cord monitoring during the second stage posterior fusion, it is not typically implemented by most neurosurgeons or by myself, simply because, we are not working on or around the spinal cord and therefore, no injury is anticipated.
About the author
Dr. Faiza Jibril
Dr. Faiza Jibril has extensive clinical experience ranging from primary care in the United Kingdom, to pediatrics and child abuse prevention at Mount Sinai Hospital, to obstetrics in Cape Town, South Africa. Her post-graduate education centered on clinical research and medical ethics. Dr. Jibril is currently Head of Sales in the US and Canada for Chambers and Partners - a world leading legal ranking and insights intelligence company.
