51yo female who had a previous left leg amputation in the 1970s from osteosarcoma when she was a child. Also history of scoliosis and phantom limb syndrome. MD elected to place a trial spinal stimulator to alleviate her chronic leg pain.
OP NOTE ATTACHED AS PHOTO
Day one after the procedure, PC complained of reduced sensation in her right extremity with progressively worsening pain and loss of motor function. PC goes to ER and stimulator removed and subsequent MRI results as:
No evidence of epidural mass or cord compression.
Evaluation of the thoracic cord signal is limited by decreased signal-to-noise ratio. However there is no gross abnormal cord expansion and no gross epidural mass or cord compression.
Chronic T10 and T11 vertebral body compression fracture with post kyphoplasty changes and associated focal kyphotic deformity without significant central canal or neural foraminal stenosis.
No retropulsion of bone fragments.
PC saw a neurosurgeon 3 times post op and was told that she had permanent cord damage. Apparent new post-op symptoms have further her mobility. PC was limited as it was, but now she is wheelchair bound and has difficulty with urinating due to loss of sensation to her pelvic area. She is also no longer able to drive, which she was able to prior.
We currently have no further update concerning follow-up for EMG/MRI, etc.
We seek the opinion of a Pain management and rehab provider who could speak to the following concerns:
Is the spinal cord stimulator insertion a deviation based on her history?
Is the Operative note within the standard of care?
Was this avoidable or just an unfortunate outcome/recognized complication?
Other unlisted issues?
We appreciate your time in advance.
Files:
No questions yet!
Do you believe there might have been medical error?
The choice of placing a trial spin accord stimulator for a patient with Phantom syndrome is considered standard of care. Phantom Lim syndrome is an accepted diagnosis for which spinal cord stimulation may be prescribed. The patient complained of symptoms, the first day after the procedure, the position then promptly removed the trial stimulator which I believe was appropriate. The MRI that I reviewed showed no evidence of cord or epidural abscess or compression. The Only criteria for claiming there was a medical injury was the fact the patient claims all her issues were new onset post procedure. But based on the history, I read, operative note, and immediate actions the physician. there are no obvious physician issues. Now, if a follow on MRI shows abnormality which could be attributed to placement with Spinal Cord Stimulator The answer might be different.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The argument for the procedure causing the issue was the patient’s claim there no difficulties prior to The Spinal Cord Stimulator trial.
What makes you a good expert for this case?
I’m a board-certified interventional Physiatrist and I placed numerous Spinal Cord Stimulator trials as well as permanents.
How often do you encounter cases similar to this one in your practice?
Thankfully, personally rarely. Period however I have been retained on several spinosum cases, both on the plaintiff as well as defense side.
Do you believe there might have been medical error?
Based on the limited available information I have, I am unable to make a clear determination of medical error. The op report indicated general anesthesia was used, which would be a deviation of standard of care for a stimulator trial and could potentially expose the patient to unnecessary risk however based on the anesthetic drugs administered it seems that the patient in actuality received conscious sedation not general anesthesia. Spinal cord injury from a spinal cord stimulator placement is a known possible complication that can result without deviation from standard care. However, if there was direct cord damage during the procedure, I wouldn't expect it to take until the next day for the patient to notice symptoms from this injury. It is unclear from the available information what occurred in this case to cause injury.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, I am unable to make a determination of error from the available information with any certainty.
What makes you a good expert for this case?
I am a board-certified pain management physician with over 10 years experience performing spinal cord stimulator trials and implants. I am on faculty for multiple spinal cord stimulator device companies and educate other doctors nationally how to safely perform these procedures.
How often do you encounter cases similar to this one in your practice?
Fortunately, I have never performed a spinal cord stimulator trial or implant that resulted in injury.
Want to open a case or submit response?
Comments are accepted only from Pain Medicine (Physical Medicine and Rehabilitation) experts.