TIMELINE: On April 17, 2025, client had an L2-L3 laminectomy for stenosis with neurogenic claudication. Two days later, client presented to the ED at Hospital via EMS on April 19, 2025, at 22:25 hours with excruciating back pain with numbness of his lower extremities. On examination, he had diminished rectal tone, and he was unresponsive to painful stimuli in his lower extremities. On April 20, 2025, at 1:18 a.m. an MRI of the lumbar spine finds: Post laminectomy changes at L1-L2 and L2-L3 with fluid within the laminectomy bed compressing the posterior aspect of the thecal sac. Left hemilaminectomy changes at L5-S1. On April 20, 2025, at 0223 hours, neurosurgeon was consulted as there was concern for cauda equina syndrome. Neurosurgeon recommended that the patient be transferred to another Medical Center for surgery in the morning and to start the patient on Decadron 10 mg. IV. On April 20, 2025, client had a lumbar wound and evacuation of epidural hematoma. Surgery was completed by 15:01 hours.
Based on the timeline, client presented on 4/19/25 at 22:25 hours and he was diagnosed, transferred, and in the OR for surgical decompression/evacuation of hematoma which was completed in less than 17 hours. Is this a deviation in the standard of care?
Client's complaint is that his surgeon was aware that he had a significant cardiac history and was on blood thinners (Eliquis), but no adjustments were made to his anticoagulant regimen leading up to or following surgery. He believes this failure allegedly allowed a spinal hematoma to form, compressing the spinal cord and causing irreversible nerve damage. Eliquis is listed on his medication record from his initial surgery & we do not believe it was stopped prior to surgery. No evidence of a hematoma at the site prior to discharge and the site was without bleeding when he was readmitted.
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No questions yet!
Do you believe there might have been medical error?
If his Eliquis was never stopped, that would be a deviation of care, clearly documented in the literature. There should also have been some time for him to be off Eliquis prior to resuming it post-operatively. Here the literature is less clear, but the routine at our hospital is a week. https://pmc.ncbi.nlm.nih.gov/articles/PMC6743676/ The other alarming comment is that the patient was transferred from the hospital at which he had his operation to another center. Was that an EMTALA violation? It seems very unusual. As a neurosurgeon who has always worked at a trauma center(so have never transferred similar patient out), this seems unsavory at best, illegal at worst. I don't think the actual timing of surgery deviates from the standard of care. Cauda equine syndrome = neurosurgical emergency. The issue(I address below), is why was the first hospital unable to take care of their own complication?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
He had a hematoma, with symptoms, requiring emergent surgery.
What makes you a good expert for this case?
Have covered a trauma center, in which I take neurosurgery and spine call, for 30+ years.
How often do you encounter cases similar to this one in your practice?
We get a weekly caudal equine call from the ER(they know it will get us there immediately). Most are not real. Most are simply to get the after hours MRI. I don't think I have ever had an outside neurosurgeon send one of their complications to us because they couldn't take care of it. If they can't take care of the complications, neither the surgeon nor the hospital should be performing the operation. Evacuation of the hematoma is actually easier than the initial decompression(not as deep, and the approach is already performed).
Do you believe there might have been medical error?
Holding apixaban for ~2–3 days before this surgery is reasonable and also dependent on risk factors from the heart standpoint. Epidural hematomas can also occur even without anticoagulation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Not every hematoma on anticoagulation equals malpractice-level causation, as these events can occur despite proper management
What makes you a good expert for this case?
I operate on complex heart patients on anticoagulation and have written on this specific topic several times
How often do you encounter cases similar to this one in your practice?
once or twice a year we encounter a similar case
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