Case Summary
This case involves a middle-aged man who underwent a spinal cord stimulator replacement surgery. Following an uneventful surgical procedure, the patient went to the intensive care unit for post-operative neurological care. The following morning, the neurosurgeon noted the patient was experiencing lower extremity weakness but that some lower extremity mobility remained. Two hours later, a registered nurse noted the patient was experiencing complete lower extremity motor loss. However, the neurosurgeon did not receive this information. After several hours, the patient underwent emergency surgery to evacuate his now-diagnosed epidural hematoma. Despite surgical intervention, he has not regained normal motor function in his lower extremities and remains paraplegic.
Case Theory
An implanted spinal cord stimulator sends low levels of electricity directly into the spinal cord to relieve pain. By stimulating the spinal cord, pain signals are interrupted prior to reaching the brain. Through the device, electrical pulses are delivered to the spinal cord, similar to a cardiac pacemaker. Many patients experience relief in chronic pain and generally use fewer opioid medications for pain relief as a result. Spinal cord stimulator implants are a frequent option for patients with chronic back, leg, or arm pain that has not responded to other therapies.
A spinal hematoma is symptomatic intraspinal bleeding that can occur spontaneously, following trauma, or as a rare complication of epidural and intradural anesthesia. Although rare, an epidural hematoma can form following the placement of an epidural spinal cord electrode. There is a link between spontaneous spinal hematomas and anticoagulant treatment, coagulation disorders, spinal malformations, and intraspinal tumors. Physicians commonly use epidural analgesia for intraoperative and postoperative analgesia during limb surgery. As a result of pain relief following epidural analgesia, the limbs can be mobilized early after surgery, reducing the risk of postoperative deep vein thrombosis.
In patients who develop an epidural hematoma, emergency decompression is necessary to facilitate the most favorable neurological outcome. In this case, negligence to act on symptoms of reduced mobility and the failure to report patient changes to the surgeon led to a failure to timely diagnose and treat the epidural hematoma, leading to paralysis.
Expert Witness Specialities
Neurosurgery
A neurosurgery expert with experience in spinal cord stimulator placement can speak to the quality of surgical and post-operative care. The expert can also opine on any deviation from accepted medical standards as well as negligence in failing to identify and timely evacuate a post-op epidural hematoma.
Critical Care Nurse
An ICU registered nurse expert can speak to the quality of post-operative care and any deviation from accepted medical standards in the failure to immediately report worsening neurological symptoms to the attending surgeon.
Questions for Expert Witnesses
- What are some measures that should be taken postoperatively to prevent morbidity from a suspected epidural hematoma?
- What is the time frame to decompress an epidural hematoma to avoid permanent damage?
- Would an earlier alert by the nurses have provided the patient with an improved prognosis?
Expert Witness Involvement
Here is what the neurosurgery expert in this case had to say:
Expert Witness Response E-007891
I perform spinal cord stimulator placement surgeries on a regular basis. Timely detection and removal of the hematoma are necessary if deemed clinically significant. I have reviewed 2 similar cases.
