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Defense Support - Paralysis Following An Epidural Injection

By: Joel L. Kent, MD
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In this case I was asked to assist in the defense of a physician who had performed a T5/6 epidural on a patient who subsequently developed an epidural hematoma and resultant spinal cord injury with paralysis.  The suit contended that the injuries sustained by the patient were the result of negligent, careless and reckless medical care.  The plaintiff made a litany of  accusations against the provider including that the  physician failed to obtain informed consent, failed to follow appropriate protocols regarding how to perform a T5/6 epidural, improperly performed the procedures, failed to perform the procedure in a manner consistent with standard of care, failed to utilize proper equipment, failed to correctly position patient for procedure, failed to appreciate clinical findings and act on them accordingly, failed to provide proper follow up, failed to appreciate signs and symptoms of an epidural hematoma, failed to timely perform a proper physical examination to diagnose the patient’s condition, failed to timely diagnose and treat an epidural hematoma in order to prevent permanent injury and failed to obtain timely consultation.

My review of the records found strong evidence to refute all of the plaintiff’s contentions.  Proper informed consent had been documented on the day of the procedure.  The physician performed the procedure with the proper technique and followed all appropriate protocols relevant to performing a T5/6 epidural injection.  The patient had been positioned properly for the procedure and proper equipment had been utilized to perform the injection.  The records indicated that the plaintiff tolerated the procedure well.  Following the procedure, it is well documented that the patient recovered in an appropriate fashion.  They were able to ambulate and were neurologically intact at the time of their discharge following the injection.  My review of the procedural documentation demonstrated that all the care that was provided to this patient by the physician and their staff was well within the standard of medical care.

Review of their medical records from later that day demonstrate this patient developed a rapidly expanding epidural hematoma that resulted in permanent spinal cord injury.  The patient was discharged from physicians practice at 15:35.  She arrived in the Emergency Department that evening at 18:58.  Their initial complaints in the Emergency Department included chest pain, back pain and leg numbness.  The initial physical exam documented the patient was able to move all extremities, had 3/5 strength in all muscle groups of the lower extremities and had diminished sensation in the right leg.  A CT scan of the chest performed at 21:26 demonstrated material in the thoracic spinal canal consistent with a hematoma.  At 21:40 it was documented that the patient had lost all sensation and motor function from the waist down.  The patient was transferred to another facility where she was treated expeditiously with a surgical decompression and evacuation of hematoma.  Despite the rapid recognition and treatment of the hematoma, the patient was left with permanent lower extremity paralysis and incontinence.

I prepared a report of my findings.  In the report I reviewed what is known regarding epidural hematomas following spinal interventions.  The formation of an epidural hematoma is a rare but well recognized complication of epidural injections.  The incidence is estimated to be 1 in 150,000 cases of epidural injection.  In the event of epidural hematoma with neurologic compromise, rapid surgical decompression is the treatment and choice and can salvage neurologic function in some cases.  Cases with rapid symptom progression and severe deficits prior to surgery, both of which were present in this case, have a relatively poor prognosis. 

I determined that the defendant did nothing in wrong in their care of this patient.  The injuries sustained were the result of a rare and known complication that was well described as a risk during the informed consent process.  While under the defendant’s care, this patient was treated properly and recovered in a normal fashion.  When discharged following the procedure, there were no signs that a serious neurologic injury would unfold several hours later.  The symptoms developed rapidly once they became evident.  This progression was so swift that even rapid diagnoses and treatment, as occurred in this case, was not adequate to allow recovery from the injury produced by the hematoma.  It was also notable that the patient never contacted the defendant regarding their escalating symptoms, so the physician did not have an opportunity to assist with their care following their discharge earlier that afternoon.

The evidence in this case indicated that the claims of negligent, careless and reckless medical care being leveled at this provider were meritless.  With the support of the findings in my report, the physician was able to mount a vigorous defense of the accusations made in this suit.  This case was ultimately settled to the defendant’s satisfaction without a trial and without any finding of wrongdoing on the part of the physician in question.

Dr. Joel L. Kent, MD, is an expert in all realms of Pain Medicine and has focused expertise in the prescribing and oversight of opioid analgesics. His specialties include acute and chronic pain management, opioid analgesics, interventional pain management therapies, spinal cord stimulation, intrathecal drug delivery, RSD/CRPS and low back pain. Dr. Kent has provided expert case reviews and testimony for over twenty years.  The majority of his expert work has focused on the standard of care in the practice of Pain Medicine and the use of opioid analgesics.  Dr. Kent has provided expert case opinions in Federal and State civil courts.

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