Case Archive
 
Neurosurgery
Ref. # 909501

A 26-year-old professional boxer, a late replacement for the scheduled fighter, endured a sustained beating during a bout. The ringside doctor, the chief medical officer with the state boxing commission, nearly stopped the fight after the seventh round but allowed it to continue, as did the referee. In the tenth round a left-right combination knocked out the boxer, who never regained consciousness. He was rushed to a hospital and underwent more than three hours of surgery to relieve pressure on the brain, followed by other procedures. Six days later he expired. Attorneys for the decedent's family brought suit against the state boxing commission, ringside physician, and emergency medical personnel. A medQuest neurosurgeon reviewed the medical records, various news accounts, and the fight videotape. The boxer suffered numerous undeflected blows that caused twisting of the head. The brain is extremely sensitive to rotational injuries, more so than straight-on blows to the head. The most damage appeared to occur in the fifth and seventh rounds, during both of which the television announcer encouraged stoppage of the fight. The tenth-round collapse was caused not by one devastating blow but by the cumulative effects of the blows from the previous rounds resulting in severe cerebral edema. A careful neurological exam focused on mental status (e.g. orientation to name, place and time) after the seventh round would likely have revealed some deficit. After the collapse the boxer lapsed into a coma, evidenced by his agitated state and lack of response to commands. Once cerebral edema begins there is often a cycle of brain swelling, lethargy, and hypoventilation that leads to more swelling. Unless the cycle is broken by therapeutic interventions, the patient can rapidly succumb to massive cerebral edema, an avoidable outcome observed in this case. If the bout had been stopped at the end of the fifth or seventh rounds, the boxer would very likely have survived.

Neurosurgery
Ref. # 779001

A 52 year-old Michigan woman had a history of spina bifida corrected surgically as an infant. A neurosurgeon evaluated her for a spastic gait attributed to left lower leg weakness. A myelogram revealed a tumor in the region of the distal spinal cord and evidence of scoliosis at the thoracolumbar junction with convexity to the right. A 5x3 cm intradural, fat-containing tumor was located anterior to the spinal cord, compressed posteriorly. A pre-operative exam included a "localizing" MRI scan. The tumor was recorded at the level of T11-T12. The neurosurgeon discussed with the family a right-sided surgical approach, as the rotary component of the scoliosis effectively reduced the angle from a straight posterior to posterolateral surgical approach. At operation the tumor was found to be "not suckable" and was removed in stages. This process necessitated rocking of the spinal cord and delivery of the tumor out from under the spinal cord. The cord was then exposed above and below and adhesions were excised with bipolar cautery and sharp dissection. The pathological diagnosis was fibrous meningioma. Post-operatively there was lower extremity paralysis and an associated sensory level at T10. The original differential diagnosis of this included a vascular accident such as a spinal cord stroke or external pressure on the spinal cord. The woman's paraplegia never improved. A medQuest neurosurgeon reported a negligent failure to perform a pre-operative angiogram of the spinal cord in order to reveal the location of the critical arteries at the surgical site. This was advisable because longstanding spinal cord tethering can distort the normal anatomy and because the fibrous changes related to the tumor frequently encases the surrounding blood vessels, exposing them to injury during surgery. There was a failure to perform intraoperative monitoring of spinal cord activity via Somatosensory Evoked Potentials (SSEP's) as favored by many spine surgeons, which would have detected changes during the "tumor rocking", enabling appropriate corrective action. The most likely etiology of the woman's paralysis was spinal cord ischemia caused by direct injury to a feeding artery, excision of an artery with the tumor, vascular damage from rocking the tumor, or laminectomy trauma.

Neurosurgery (Spine)
Ref. # 49587

A 54 year old Michigan man experienced progressive back pain, accompanied by weakness and paresthesias in both legs for one month. His history included a cervical fusion for degenerative joint disease. His primary care physician diagnosed acute lumbosacral strain and subsequently referred the patient to an MRI Diagnostic Center. A cervical scan showed spondylitic stenosis at C3-4, C5-6 and C6-7; small C3-4 disc herniation; and small to moderate C6-7 disc herniation with nerve root sleeve impingement. A lumbar scan showed mild central canal stenosis at L4-5 secondary to discogenic and facet degenerative changes. Due to increasing pain, weakness and urinary hesitancy the patient was admitted to a community hospital. He was started on Sol-Medrol and placed in a Neurovigil unit. The attending ER physician noted possible spine compression and ordered stat neurosurgical and neurological consultations. The neurology consult was performed by a physician's assistant who noted no myelopathy, no sensory level, and normal bowel/bladder function. The next day the neurosurgery consult was performed by another physician's assistant who noted no radiation of low back pain and slight gait disturbance. The patient experienced pain and weakness during the night and into the next morning. Another physician's assistant prepared the patient for discharge. An hour later the patient was suddenly unable to stand and lost sensation below the umbilicus. Two hours later stat thoracic MRIs were ordered. The scan showed a large hypointense lesion within the ventral aspect of the epidural space leading to marked cord compression at T10-11. Two hours later the attending neurosurgeon for the first time examined the patient in preparation for transthoracic laminectomy, diskectomy and vertebrectomy. The patient was subsequently transferred to a major medical center. The OR record noted because the onset of paraplegia was within the eight-hour window, surgical decompression of the thoracic disc was considered a worthwhile attempt to save the legs. The surgery was uneventful; pathology showed an intervertebral disc. The patient underwent rehabilitation but the paraplegia remained. He is wheelchair-bound and does self-catheterization for urinary dysfunction. A medQuest neurosurgeon specializing in spine surgery reported the neurosurgical consult performed by the physician's assistant was substandard. The attending neurosurgeon was negligent in failing to properly evaluate the patient in a timely manner. Due to the delay the opportunity for surgical intervention was missed and much of the patient's neurologic impairment became permanent.

Neurosurgery
Ref. # 35928

A 23 year old New York woman was brought to the ER complaining of severe headaches, vomiting and several minutes of unconsciousness. The admitting diagnosis was R/O meningitis. Antibiotics were started. Residents were unable to perform a spinal tap during the patient's seven-day stay. Twenty days later the woman was readmitted to the ER, having passed out again and suffering from severe headaches. A CT scan on admission showed a diffuse subarachnoid hemorrhage. Thirty five days later, the patient underwent surgery to clip the aneurysm, which ruptured intraoperatively, leaving the woman in a vegetative state. A medQuest neurosurgeon reported that had the hemorrhage been diagnosed one month earlier and the surgery promptly performed, the aneurysm would probably have been successfully clipped.

Neurosurgery
Ref. # 27328

A Louisiana man injured his back at work. An MRI revealed a central disc herniation at L5-S1, for which he underwent surgery. The attending neurosurgeon operated on the L4-L5 level, removing a healthy, uninjured disc, and failing o treat the ruptured disc. A medQuest neurosurgeon opined that operating on the wrong level did not in itself constitute negligence. The negligence lay in the failure to identify and correct the mistake in a fairly short time. The post-op MRI revealed scar tissue at L4-L5 but, rather than correct the mistake, the attending neurosurgeon tried to cover it up.

Neurosurgery
Ref. # 22458

A Louisiana woman underwent a lumbar laminectomy in 1992. During the procedure the treating neurosurgeon tore the dura. Prior to the patient's discharge, the registered nurse noted signs of drainage at the incisional site; nevertheless the patient was discharged. Several days later the patient was re-admitted with Group B meningitis. The attorney claims that while a tear of the dura is a recognized complication, it should have been diagnosed in a timely fashion. A medQuest neurosurgeon found several areas of negligence: the nurse's failure to inform the neurosurgeon of the drainage; the nurse's failure to identify the drainage as a CSF leak; the neurosurgeon's failure to inform the patient of the possibility of drainage; and the neurosurgeon's failure to prophylactically institute antibiotic therapy--not doing so increased the risk for fibrosis and adhesions which resulted from the infection and caused the patient's ongoing pain.

Neurosurgery
Ref. # 46458

A 37 year old Pennsylvania woman suffering severe headaches and weakness was seen in an emergency room twice, where she reported a family history of cerebral aneurysms. She was discharged without a CT scan or lumbar puncture. Ten days after the second admission she suffered an aneurysm which left her in a vegetative state. A medQuest neurosurgeon, who teaches emergency room physicians, reported that the standard of care given the patient's family history required a lumbar puncture and that the patient's current condition could have been avoided.

Neurosurgery
Ref. # 83128

A man sustained multiple trauma due to a motor vehicle accident. Initial radiology reports showed bilateral mandibular fractures, a C-6 fracture of the spinous process, and a questionable fracture at C-1. During the next two weeks the patient was noted to have progressive weakness. He was allowed out of bed. A cervical lateral X-ray showed perching of his facets and angulation at C5-6. The patient developed a dislocated facet at C5-6, resulting in quadriplegia. He was placed in traction and fused, with no improvement in his condition. Two medQuest neurosurgeons independently reported negligent assessment and treatment of the patient's cervical subluxation. The attending physicians failed to obtain a CT scan, stressing a view of the complete spine. A cervical collar did not immobilize the patient adequately. His paralysis was preventable.

Neurosurgery
Ref. # 39058

A 15 year old Massachusetts woman sustained multiple trauma in an MVA and was transported to the ER of a local medical center, not a designated trauma center. A CT scan showed soft tissue swelling overlying the right occipital bone, small focus of increased attenuation in the left frontal region, and air fluid level in the right sphenoid sinus. The impression was small frontal contusion and suspected basilar skull fracture. The patient was admitted to the ICU, with planned neurosurgical and orthopedic consults. Five hours later, a neurosurgeon diagnosed probable cerebral contusion as manifested by left gaze paresis, speech deficit and possible right-sided motor deficit. Treatment included Mannitol, potassium and IV Dilantin. During the next day the patient became restless, incoherent and at times unresponsive, according to nursing. That evening a code was called for superventricular tachycardia. The patient lapsed into a coma with a flat EEG. The next day she was disconnected from the ventilator and pronounced dead. A medQuest neurosurgeon opined that in the ER the patient showed symptoms of impending herniation, including abnormal neurological signs and positive bilateral Babinskys. The attending physicians deviated from the standard of care, which required intubation, bolting, ICP monitoring, and thorough evaluation in a neurological ICU. With timely diagnosis and treatment, the patient's chances for survival would have improved immeasurably.




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