Aaron is a 12 y.o. 4 m.o. male with a history of congenital kyphosis of thoracic region initially diagnosed with scoliosis at age 6 in 2018 for which he wore a brace and was monitored at a Hospital in South Carolina. Family moved to Florida in 2023. Aaron underwent a posterior spinal fusion with instrumentation, multiple thoracic Ponte osteotomies, and 3 column osteotomy at the level of T6 on 2/03/2025. However, towards the end of the correction, there was loss of motor signals to bilateral lower extremities so correction of kyphosis was aborted and patient fused in situ. MRI of the spine after the procedure demonstrated a focal linear smooth dark signal in the posterior canal at T6 which is unclear if it is blood or air. Aaron remained intubated and sedated on arrival to the PICU post-operatively. PM&R was consulted due history of a spinal cord injury, and need for inpatient rehab. Aaron was lying in bed with HOB elevated, parents present at the bedside. On room air. Tolerating PO intake. Wound vac remains in place. Parents and Aaron report no movement bilateral lower extremities with no sensation below umbilicus. Mother reports that prior to this admission, he was independent with mobility, transfers, and ambulation with no functional limitations, however, sometimes had trouble keeping up with peers so would pace himself. History of idiopathic toe walking with tight ankles per mother for which he wore braces in the past. Aaron was reviewed with therapists this AM during weekly team conference. PT and OT evaluations pending.
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Impression:
1. Congenital kyphosis of thoracic region
2. Encounter for vitamin deficiency screening
3. Chronic bilateral thoracic back pain
PLAN: Aaron returns for reevaluation of his scoliosis prior to proposed surgery with Dr. N. and Dr. B. on 2/3/25:
posterior spinal fusion with instrumentation, multiple thoracic Ponte osteotomies by Dr. N. and 3-column osteotomy at the level of T6 by Dr. B. The expected procedure and postop course were discussed with the patient and the family today. The appropriate risks, benefits, and alternatives were reviewed. They understand to my satisfaction, and wish to proceed.
Specific risks discussed included, but were not limited to blood loss, infection, tendon damage, nerve damage including paralysis, anesthetic complications, death, failure of surgery to achieve desired goals, and need for future surgeries. The family was informed that medications, bone graft material, and instrumentation may be used in an "offlabel" manner when in the best interest of the patient, according to the discretion of the treating physicians. There were no barriers to communication. The family understands to my satisfaction and wishes to proceed.
The family understands other members of the surgical team may help with the case.
TEACHING/SUPERVISING PHYSICIAN'S ATTESTATION:
I have reviewed the history and examined the patient. I concur with the findings, personally delineated the plans as transcribed by the on duty resident Dr. P., and add the following revisions:
"Wyatt" was admitted to the PICU at the request of Dr. KN/orthopedic surgery — as noted in the main body of the H&P, he lost motor and somatosensory evoked potentials as he neared completion of an elective posterior spinal fusion with instrumentation, so traction was released and completion of the procedure was deferred. Neurosurgery was consulted emergently, and a T6 decompressive laminectomy was performed. There was no return of motor and sensory potentials, however. He was kept intubated and brought to MRI, and subsequently brought to the PICU.
OP NOTE by Dr. B. [2/3/2025]:
Operative Details:
The patient was brought to the operating room, administered a general anesthethic by the department of anesthesia, and positioned by Dr. N.
Dr. N. commenced the surgery and called me to the room after exposure, O-Arm spin and placement of screws. MAP was requested to be at 85.
Utilizing Stealth neuronavigation, I identified the 2h emivertebrae at T5. I then commenced a decompressive laminectomy and facetectomy of the T5 laminar complex.
Following, I dissected the soft tissues away from the bilateral hemivertebrae, and proceeded to resect them with a high-powered drill. Commencing with the left, I drilled down, through the pedicle. I proceeded to resect the hemivertebra until disc was noted superiorly, inferiorly and medially, with soft tissue noted laterally.I performed the similar maneuver on the right, drilling down through the pedicle into the hemivertebrae. Ensuring disc material superiorly, medially and inferiorly and soft tissue laterally. During these resections, the spinal cord was protected and MEPs were performed approximately every 5-10 minutes without any changes. No changes in SSEPs were noted either during the hemivertebrae resection. Neuronavigation confirmed resection of the hemivertebrae. Patient was noted to have significant epidural fat that was resected over the T5 area until normal cord was noted, so it could be visualized during correction. Neuromonitoring signals were checked again, and noted to be stable. Rods were then contoured and placed by Dr N. With correction utilizing the rods, the spinal cord remained without tension nor compression. MEPs were performed frequently. However at the end of the correction MEPs to the lower extremities were lost. Rods were released and removed. Multiple maneuvers including increasing MAP, checking hemoglobin, blood products given, cold saline to the cord, steroids were performed. MEPs did not improve and SSEPs were decreased as well. I inspected the osteotomy and didn't find any ventral nor dorsal compression. We re-imaged with O-Arm to confirm no ventral compression. He had no dorsal compression, however to ensure there was no pinching of the cord inferiorly, I performed a central T6 decompressive laminectomy and resection of epidural fat. A Woodson elevator passed easily superiorly and inferiorly to the osteotomy and laminectomy. There were no improvement in his signals, thus no further correction and Dr. N. fused him in situ, with plan for postoperative MRI.The incision was then closed by Dr. N."
Files:
No questions yet!
Do you believe there might have been medical error?
Unable to determine, as there is very little medical information available, unfortunately. Would need radiographic imaging, intraoperative notes, and more, in order to have at least an idea of what is occurring here.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unable to determine, as there is very little medical information available, unfortunately. Would need radiographic imaging, intraoperative notes, and more, in order to have at least an idea of what is occurring here.
What makes you a good expert for this case?
I am a board-certified orthopedic surgeon, diplomate of the ABOS, and have significant experience reviewing med mal Orthopedic Surgery cases.
How often do you encounter cases similar to this one in your practice?
Thankfully, it is infrequent. This is an unfortunate outcome.
Do you believe there might have been medical error?
This is a high riskspinal deformity procedure. The fact that the child had toe walking and tight hamstrings pre-op indicates a mild spasticity, or spinal cord compromise pre-op. I have had similar inter-operative injuries in similar procedures. The operative description indicates appropriate monitoring with MEPs, SSEPs, and imaging as well as appropriate intervention in the laminectomy and aborted kyphosis correction. There does not appear to have been an inter-operative error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
manipulation of a compromised spinal cord with severe kyphosis is a risky operation and undoubtedly the child did suffer an inter-operative spinal cord injury.
What makes you a good expert for this case?
I have done many such cases over the years although more in adults than children. However, I have done such cases in children several times also. This particular type of deformity is very rare and very dangerous with or without surgery for spinal cord compromise. It is typically only done by experienced deformity surgeons in tertiary care centers. The only concern I could imagine here would be if the surgeon was operating on pathology that is beyond his skill and experience, or that of the hospital. My impression reading the op not however is that that is not the case.
How often do you encounter cases similar to this one in your practice?
I did dozens of spinal deformity cases each year over 25 years in practice. I am retired since 9/2023.
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