Patient was having some numbness and decreased strength in bilateral hands and arms. Dr. X did an xray and MRI and found that patient had cervical spinal stenosis. Dr. X referred patient to Dr. Y, an Ortho Surgeon.
After seeing Dr. Y on 5/22/25, it was suggested that patient have a spinal steroid injection before going straight to surgery. When patient couldn’t get the injection for various reasons, patient called back for another appointment. Patient’s next appointment was on 7/8/25, and patient’s surgery was set up for 8/8/25. Surgery went as planned and patient was sent home on the day of surgery. Patient recuperated at her sister’s house , almost 2 weeks postoperatively patient’s incision started draining and patient started running fever. Initially patient was started on antibiotics hoping it was a superficial infection.
8/21/25, Patient went to the emergency department and was admitted after the second visit and an MRI was performed. Dr. Y thought that any of the fluid collection seen was appropriate postoperatively, but patient had blood cultures done at the ED as well.
On 8/23/25 Dr. Y took patient to the operating room for an incision and drainage and a wash out. Patient’s blood cultures and cultures from her wound drainage both came back positive for Serratia. After the wash out, Patient continued to have fever and positive blood cultures which they drew daily.
When Patient woke from this second surgery patient’s arm felt paralyzed, she could not move her shoulder, elbow or wrist initially. Another MRI was ordered and the infection was seen closer to patient’s spine so Dr. Y decided Patient needed another surgery, this time Dr. Y went down to Patient’s cervical spine and saw that PAtient’s bone was infected and Dr. Y had to remove the previous hardware and extend Patient’s fusion from C5-7 to C4-7.
Patient’s arm continued to have the same deficits from after the second surgery. Patient no longer had the numbness or decreased strength in both arms, but Patient just could not move her left shoulder elbow or wrist. Since Patient’s infection went to the bone and also touched the C5 nerve root which was the cause of her “palsy”. Patient started home health nursing and was given twice a day intravenous antibiotics for 6 weeks. Patient also started physical therapy and has some movement back in her wrist, elbow but still unable to lift or raise her shoulder.
On 10/2/25, Patient started running another fever and went to the emergency department in local city and found to have leukopenia (low white blood cells) caused by the antibiotics. Patient’s bloodwork from 10/1/25 done by the nurse weekly showed the same as above. There was no physician checking Patient’s labs and they were not being monitored. Patient stayed in the hospital for another 4 days through the weekend.
On 10/10/25, Patient saw the infectious disease physician and was started on another antibiotic by mouth twice a day for approximately 1 year. Infectious Disease Physician also expressed in his note that Patient’s infection came from complications from my first surgery.
Lastly I saw Dr. Z, an upper extremity specialist and Dr. Z would like to perform a nerve transposition to help with the muscle in Patient’s left arm not having any nerve innervation. Patient had testing for this on 1/5/26, and is now setup for surgery for this on 1/30/26.
Was Dr. Y negligent in the 1st surgery and how he handled Patient’s care?
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No questions yet!
Do you believe there might have been medical error?
Infection is extremely rare after ACDF. While infection by itself does not indicate negligence the delays and lack of follow up may. Also the occurrence of a neuro deficit post I&D may well. Would depend on chart/imaging. But the outcome is not typical by a long stretch and the lack of further follow up with the surgeon suggests negligence
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If there is an error or negligence causation is clear. I’m wondering whether there may have been an esophageal injury or gross contamination of the wound somehow. But the complication was caused by the surgery, no question
What makes you a good expert for this case?
I am retired after 25 years as a spine surgeon but I have done thousands of similar cases. I also have written hundreds of papers and given dozens of talks. As well as taught over 50 spine fellows from both ortho and neuro backgrounds. Also have done a couple dozen expert witness cases over the years…
How often do you encounter cases similar to this one in your practice?
ACDF is extremely common. Complications like this one (infection and neuro deficit) both extremely rare
Do you believe there might have been medical error?
Dr. Y provided appropriate treatment for infection after ACDF, which is a known complication of surgery. It is unclear if any medical error resulted in C5 palsy or was it due to infection.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is unclear if any medical error resulted in C5 palsy or was it due to infection.
What makes you a good expert for this case?
I am an orthopedic spine surgeon and routinely perform ACDF.
How often do you encounter cases similar to this one in your practice?
I perform ACDF surgery on a routine basis.
Do you believe there might have been medical error?
Based on what was presented in the synopsis, it appears everything went well with the first surgery. Although rare infections can occur following ACDFs. The physician appeared to treat appropriately. Also C5 palsies are rare but can occur following ACDF. Based on what has been presented there was no negligence
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unfortunately the infection and c5 palsy occurred but this does not suggest any negligence
What makes you a good expert for this case?
I am a spine surgeon who does ACDFs and have had 2 infections in my career and a couple of C5 palsies following ACDF.
How often do you encounter cases similar to this one in your practice?
Rarely but they can happen. I am a spine surgeon who regular performs ACDF and has had 2 infections from the anterior approach and maybe 2 C5 palsies. Again this does not mean that there was any negligence.
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