PC is a 60-year-old gentleman with increasing left hip pain over about 2 years. He has been seeing pain management for conservative therapy. Prior to the procedure in question, PC was active, able to ambulate normally, golf, very active lifestyle. The medical group he was seeing informed him that there was a new procedure that they had created called The “**** plasma rhizotomy”. (Name is redacted due to the procedure being same name as the potential defendant). They told him he would be only the third person to ever receive this procedure and that it would provide “total and complete resolution” to his symptoms. PC contends that they persisted to do this procedure for about 3 to 4 months until he finally consented to it. In doing research for this case, we have consulted multiple physicians who have been unable to fully corroborate the history of this particular procedure.
**Attached to this case you will find the brochure (redacted to not show name of the facility) the office gives patients to explain the procedure.**
PC has procedure done in October of 2023. Immediately post up, PC develops left side of extremity numbness and pain, shooting and jolting burning to his hamstring and calf area. Also states his left foot has severely diminished sensation. Has fallen multiple times since the procedure. PC had multiple follow-ups with the office that did the procedure and was told that his symptoms would subside “eventually”. They elected to do a lumbar spine MRI, unknown why they did not do radiology on the hip itself. When unsatisfied with this care, PC sought outside referral and he was told that he had a substantial sciatic injury.
Below, you will find the original operative note, the lumbar MRI that was done postoperatively and two EMG studies. Note that one EMG study was done by the same office that performed the rhizotomy and another EMG that was performed by an outpatient facility that did NOT perform the rhizotomy.
We spoke to PC earlier this week and he states that still continues to have the same symptoms despite months of physical therapy and medication.
We are looking for a pain management physician who would be able to speak to the legitimacy of the plasma rhizotomy and it's clincal indications for our client. In addition, we would like to know if the operative note would lend to the theory that our PC’s sciatic injury was caused by this procedure.
ORIGINAL OP NOTE:
At first, the patient was taken to the pre-operative area and an IV access was obtained. The patient was given clindamycin 900 mg via IVPB 45 minutes prior to the procedure. IV fluids were started as peranesthesiologist instructions.
After that, the patient was taken to the operating room and placed in the supine position first on the operating table. Fluoroscopy was used to perform this procedure. At first, the ultrasound was used for both the articular branches of femoral and obturator nerve DPRs to identify and mark the femoral neurovascular bundle. After that, the anterior hip area was prepped and draped in a usual sterile manner. Intended injection sites were marked using fluoroscopic guidance. Xylocaine 2% was used asa local anesthetic at each injection site. Then, the targeted sites for the DPR were 1to 2 cmcephalad to the Left hip joint and just inferior to the anterior inferior iliac spine for the articular branch of the femoral nerve. For the articular branch ofthe obturator nerve, the target was on the teardrop appearance of the junction of the ischium and the pubis inferiorly. After anesthetizing the incision sites, a #11 blade was used to make a small 3 mm in size incision at each intended level. After that, the plasma was applied directly to the intended articular branches of femoral nerve and obturator nerve using a Bovie with a guarded tip. The articular branches of the Left femoral and Left obturator nerve were lesioned. After that, the patient was placed in the prone position. Intended injection sites were marked using a fluoroscopic guidance. Xylocaine 2%was again used as a local anesthetic at each injection site. Intended DPR sites were 1to 2 cmcephalad to the Left hip joint at 12 o’clock position for the articular branch of the Left superior gluteal nerve. For the articular branch of the nerve to quadratus femoris, the DPR site was on the pubic bone just medial to the hip joint at the level of fovea of the femoral head. After anesthetizing the intended DPR sites, again #11 blade was used to make a small 3 mm in size incision at each intended level. After that, the plasma was applied directly to the articular branches ofLeft superior gluteal and nerve to quadratus femoris using a Bovie with a guarded tip. The Plasma Rhizotomy was performed for articular branches of Left femoral obturator, superior gluteal, and nerve to quadratus femoris today. Total of four nerves were lesioned using DPR technique Permanent images have been recorded and stored electronically. At the conclusion of the procedure, the Bovie was removed and pressure was applied. Sterile Steri-Strip bandages were applied over the incision sites. The patient tolerated the procedure well. The patient’s vital signs were monitored during this procedure and remained within normal limits. There were no complications. Post-procedure vital signs remained normal as well. Estimated blood loss was about 0 cc.
POST OP EMG (PERFORMED BY OFFICE THAT DID THE RHIZOTOMY)
IMPRESSIONS:
This study reveals evidence of acute left L5, S1 radiculopathy.
The Above electrodiagnostic study reveals abnormal left peroneal and tibial nerve study. This finding is most probably secondary to atrophy of the EDB muscle and abductor hallucis muscle seen on physical exam rather than any pathological process however cannot 100% rule out a peroneal or tibial neuropathy. Correlate clinically.
The above electrodiagnostic study reveals no evidence ofperipheral neuropathy, motor neuron disease Test results were discussed with the patient and questions were answered. or lumbosacral plexopathy at this time.
POST OP Lumbar Spine MRI
IMPRESSION:
1. Stable lumbar spondylosis and degenerative disc disease in comparison to prior study with no evidence for a new focal nuclear herniation.
2. Stable disproportionate spondylosis L4-L5 interspace with foraminal narrowing as described.
3. New partial visualization of right renal lower pole nodule, indeterminate as discussed. I would suggest correlation with renal ultrasound.
4. Please see in-depth discussion in body of report.
POST OP EMG (NOT DONE AT OFFICE THAT PERFORMED THE RHIZOTOMY)
Needle EMG was completed in the lower extremities bilaterally sampling representative muscle groups at rest, with minimal effort and with maximal effort including the following muscles (with additional muscles sampled as clinically indicated and notated on the EMG sheet): Gluteus Medius (superior gluteal nerve, L4,L5>S1), Vastus Lateralis (femoral nerve, L3,L4>L2), Semimembranosus (sciatic nerve,S1>L5&S2), Tibialis anterior (deep peroneal nerve,L4>L5), Gastrocnemius (anterior tibial nerve,L4¢>L5), Peroneus Longus (superficial peroneal nerve,L5,S1) and Lumbar Paraspinal muscles. There is 3- motor unit drop out and 3+increased insertional activity in the left anterior tibialis, peroneus longus, medial gastrocnemius, posterior tibialis, semimembranosus and biceps femoris (long head) muscles with chronic neurogenic changes and evidence of renovation, including motor unit action potentials of increased amplitude and duration. There are normal needle EMG findings in the left gluteus medius and gluteus maximus muscles making a sacral plexopathy unlikely. There are no fasciculations. There is no increased insertional activity in the lower lumbosacra! paraspinal muscles bilaterally.
NERVE CONDUCTION STUDIES
NCS were completed in the lower extremities bilaterally including: RIGHT Peroneal nerve motor conduction with Peroneal nerve F wave LEFT Peroneal nerve motor conduction with Peroneal nerve F wave RIGHT Tibial nerve motor conduction with Tibial nerve F wave LEFT Tibial nerve motor conduction with Tibial nerve F wave RIGHT Tibial nerve H-reflex LEFT Tibial nerve H-reflex RIGHT Sural nerve sensory conduction RIGHT Medial Plantar nerve sensory conduction (as per Saeed and Gatens) LEFT Medial Plantar nerve sensory conduction (as per Saeed and Gatens) RIGHT Lateral Plantar nerve sensory conduction {as per Saeed and Gatens) LEFT Lateral Plantar nerve sensory conduction (as per Saeed and Gatens)
There is left Peroneal Motor distal latency prolongation with diminished amplitude of response and conduction velocity slowing. The left tibial motor response is unattainable.
Impressions:
This is an abnormal electrodiagnostic evaluation of the lower extremities with evidence of:
1. Chronic Active Left sciatic neuropathy with evidence of ongoing denervation a needle EMG.
We appreciate your time and opinion in advance.
Files:
Q: Where did this physician train?
A: NHL MUNICIPAL MEDICAL COLLEGE, SOUND SHORE MEDICAL CENTER, NEW YORK UNIVERSITY MEDICAL CENTER and THE FLORIDA SPINE INSTITUTE
Do you believe there might have been medical error?
I can go in details when I review the case, however in short, it seems that upon looking at a NCS thereafter there was damage to the sciatic nerve. This nerve is usually not affected otherwise. It seems as if there is some 'leakage' of plasma and/or inadvertent damage done to the nerves.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, given this is not a 'usual' procedure that is done as an interventional pain management physician, I believe there is some merit here.
What makes you a good expert for this case?
I am double board certified in anesthesiology and interventional pain management. I am the program director for the pain fellowship program at my institution. I am very clinical and perform over 150 procedures monthly.
How often do you encounter cases similar to this one in your practice?
Upon occasion, however not this specific case.
Do you believe there might have been medical error?
I was involved in preparing a lecture and training block for a medical device company. We spent the entire time designing the lectures and cadaveric pictures for shoulder and hip radio frequency ablation. On the last day of the meeting we decided the procedures were too dangerous to teach.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I’m ’not sure the procedure was done improperly, but the procedure. Has inherent risks.
What makes you a good expert for this case?
Not saying that I am. Just this is an interesting format and procedure.
How often do you encounter cases similar to this one in your practice?
I haven’t heard of plasma ablation.
Do you believe there might have been medical error?
The procedure in question that was performed is a deviation of the standard of care in pain management. From the operative description, it seems this surgeon performed a variation of a standard radiofrequency ablation for chronic hip pain. The standard procedure uses cooled or traditional radiofrequency ablation needles to denervate the hip joint by targeting the sensory branches of the femoral and obturator nerves using an anterior superior and medial approach to the joint. Where this surgeon deviated from that accepted procedure is where he used electrocautery (the bovie or "plasma") to perform the ablation. While this technique could in theory provide the patient with longer-lasting relief, the potential for more serious and permanent nerve injury is greater. He again deviated from the standard accepted procedure by targeting the posterior branches (superior gluteal and nerve to quadratus femoris). Ablation of these nerves is not typically performed due to risk of sciatic nerve injury which occurred in this case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In the operative report it is noted that ultrasound guidance was used to identify and mark out the femoral neurovascular bundle to avoid injury during the procedure. This is standard best practice. However, when performing the posterior nerve destruction, the report doesn't document that he used the same technique to identify and mark out the sciatic nerve. This is where the injury occurred. It is unclear why this precaution was taken on the anterior approach but not the posterior. Using ultrasound to identify the sciatic nerve could have avoided this complication.
What makes you a good expert for this case?
I am a pain management physician with over 10 years of experience and routinely perform radiofrequency ablation procedures similar to the procedure in question.
How often do you encounter cases similar to this one in your practice?
This procedure is a variation on traditional radiofrequency ablation, a procedure I perform on a weekly basis in my practice.
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