Timeline:
July 2024 — SCS device failure. Patient reports device has been "dead since July 2024." Told she cannot receive a battery-only replacement; the outdated paddle must be replaced as well. Patient researches alternatives and requests Boston Scientific system.
08/05/2024 — Diagnostic Imaging: CT thoracic spine W/O contrast: Dorsal kyphosis, mild scoliosis, SCS electrodes extending to T10, mild stenosis posterolaterally at T10-T11, laminar defect at T11-T12 — no significant interval change vs. 07/07/2023 comparison. CT lumbar spine W/O contrast: Levoscoliosis, extensive postoperative changes L4-S1, pedicle screws at L4/L5/S1, disc prosthesis at L4-L5 and L5-S1, Grade 1 spondylolisthesis L5-S1.
10/28/2024 - Initial Neurosurgery Consultation: Patient is a 74 y/o female referred by pain management for SCS removal/replacement evaluation. CT from 08/05/24 reviewed. Leads documented at T10-T11; SCS battery in left abdomen; pain pump on right side. New pain in low back and chronic pain down right leg (sequela of prior Bonati spine injury). Plan: SCS removal/replacement with new Boston Scientific system.
11/15/2024, 09:36 AM - Patient admitted as elective inpatient by Neurosurgery Admitting diagnosis: Other vascular myelopathies. Operative Procedure: Spinal cord stimulator removal and replacement — two surgical preps: First prep (supine): Left abdomen — old battery explanted; lead extensions cut; wound closed. Second prep (prone): Thoracic — old SCS extensions and thoracic paddle lead removed via thoracic laminectomy centered at T9-T10. New incisions created. Battery pocket opened. On advancement of new lead, CSF was noted. Decision made: new lead NOT implanted. Abandoned. Thoracic laminectomy defect sealed with Duragen dural graft + Adherus green glue. Wounds closed in layers (Vicryl, monocryl, Dermabond). EBL: 25 mL. Entire old system explanted; patient is now MRI-compatible. Surgical Operative note: "Complications: None; patient tolerated the procedure well." PA's brief operative note: "Complications: Unintended durotomy, repaired."
11/18/2024 MRI thoracic spine WO contrast — finalized. Cord edema at T9-T10 with asymmetric punctate T2 hyperintense signal involving the left hemicord — etiology/acuity uncertain; prior cross-sectional imaging unavailable; possible recent cortical infarction vs. trauma considered. Laminectomy defect centered at T10 with surgical changes; mild dorsal cord bulging without high-grade compression. Spinal canal stenosis at T10-T11 on the right with impingement of right hemicord; focal T2 signal suggesting trace edema and/or myelomalacia. At 06:00 PM — DISCHARGED to Inpatient Rehab Facility. Discharge Status: "Still with some lower extremity weakness on left." Cleared by neurosurgery. Continue steroids, home meds. Follow-up with PCP and Neurosurgery.
INPATIENT REHABILITATION (11/18/2024 – 11/30/2024) — Inpatient rehabilitation. At discharge from hospital: patient could not move left leg or toes.
12/02/2024 - Post-Op Follow-Up: Neurosurgery. Post-op SCS removal follow-up. Presents in wheelchair. Developed LLE weakness and left foot drop following surgery — attributed to CSF leak and possible spinal cord injury. Motor strength: LLE 1/5 to left plantar and dorsiflexion (CN II-XII intact, A&O x3). Urination difficulty persisting. Severe electrical shock-like pain in both legs. Hypertension difficult to control due to pain. Incisions clean/dry/intact. Assessment: Failed back syndrome (M96.1). "She is recovering from spinal cord injury." Plan: Follow-up 6 weeks; Consider urology consult for neurogenic bladder; Pain management— consider DRG stimulator; would not recommend SCS stimulator again; referral for home health nurse + home PT/OT.
01/16/2025 — Follow-up at Orlando Neurosurgery 6-week follow-up. Continues with difficulties consistent with spinal cord injury. Bowel: requires daily Miralax. Urinary: incontinence at night and daytime at times. Numbness right knee down; weak left leg (AFO brace tried but high arches prevented fit). Milestone: Able to stand unassisted — "wasn't able to do that at Christmas just 3 weeks ago." Becoming depressed, losing hope. Doing home PT daily. New pain left low back (neuropathic. Patient not interested in antidepressants. Diagnosis: Failed back syndrome, Spinal cord injury thoracic region
02/20/2025 — Follow-up at Neurosurgery 5-week recheck (spinal injury). "Small improvements." Asking about stem cell treatment. Pain in abdomen, core, and weakness more on left side. Getting up and able to stand and move around. Switched rehab facility. Exam: Motor 5/5 UE; RLE 4/5, LLE 3/5; left foot drop (able to dorsiflex weakly); numb from right knee down. Diagnosis: Failed back syndrome; Spinal cord injury thoracic region.
04/03/2025 6-week follow-up. Left hip drops and drags. Learning to walk again with hip dropping. Low back and hips are extremely painful. Stomach painful. Able to walk around house but no longer distances due to pain. Exam: Same (RLE 4/5, LLE 3/5, left foot drop with weak dorsiflexion, numb right knee down). Plan: Radiofrequency ablations (nerve burns at 5 levels in back); Consider adding baclofen to intrathecal pump (mixed with fentanyl). Diagnosis: Failed back syndrome, Spinal cord injury thoracic region.
05/15/2025 6-week follow-up. Functional improvement: Working outside the home; able to go to the shopping center and push a shopping cart. Persistent deficits: Bowel/bladder control issues continuing. On Miralax and stool softeners daily. Intrathecal pump delivering fentanyl only (medication changed from prior). Exam: Same (RLE 4/5, LLE 3/5, left foot drop with weak dorsiflexion, numb right knee down).
09/04/2025 — Most recent follow-up "About the same." Left side still dragging. Pain left side groin to breast. Feels "stable." Improvements occurring in PT. Functional losses: Sold car because couldn't use (couldn't install a hitch). Purchased a vehicle with an interior lift (Lincoln Aviator). Using motorized wheelchair. Difficult to walk across the house. Exam: Motor 5/5 UE; RLE 4/5, LLE 3/5 (able to stand a few minutes unassisted); left foot drop — weak dorsiflexion; numbness right knee down. Diagnosis: Failed back syndrome, Spinal cord injury thoracic region.
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Do you believe there might have been medical error?
The CSF leak/spinal cord injury was not the intended outcome. I'm going to suggest your question is limited. There was clearly a medical error. I do not think it rises to the level of a deviation from the standard of care. You have a multiply operated elderly female with an implant so old it is no longer compatible with current technology. CSF leaks have been clearly documented to occur in this setting. Spinal cord injury is rare but a known complication of this procedure.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
She had new symptoms after surgery, with MRI confirmation of injury at the level of her surgery
What makes you a good expert for this case?
30+ year history of taking neurosurgical/spinal trauma call at trauma centers. I like the techie stuff(aerospace engineer undergrad), with an interest in neuro-modulation(SCS, pain pumps)
How often do you encounter cases similar to this one in your practice?
We take care of spinal cord stimulators weekly. I have never seen a permanent neurological deficit from these cases(but every time I have to replace the leads, I ask the resident why I allowed them to talk me into this case).
Do you believe there might have been medical error?
The amount of force necessary to push this device into the dura and spinal cord and the severity and persistence of the patient’s deficits, combined with postoperative imaging suggesting spinal cord trauma or infarction, make a deviation from the standard of care. The discrepancy between the surgeon’s operative report stating “no complications” and the PA note documenting an “unintended durotomy, repaired” raises concern regarding the concern for careless or excessively forceful surgical technique.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a strong temporal and clinical relationship between the surgery and the patient’s injuries. Before surgery, the patient had chronic pain but was ambulatory and functioning independently. Immediately after surgery, she developed profound neurologic defiticit. This was also seen on MRI. Treating neurosurgery providers repeatedly documented that the patient was recovering from a thoracic spinal cord injury. The available records strongly support that the postoperative neurologic deficits were caused by the surgical event.
What makes you a good expert for this case?
I am familiar with postoperative neurologic complications following spine surgery. I am experienced in reviewing causation, standard-of-care issues, operative documentation, and postoperative rehabilitation courses in complex spine cases.
How often do you encounter cases similar to this one in your practice?
I encounter postoperative spine surgery complications and chronic pain/spinal cord stimulator cases on a regular basis.
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