This case involves an elderly patient who suffered injuries from a fall in his shower. He was taken to the hospital where he was diagnosed with a neck fracture. On admission to the hospital’s emergency department, his neurological examination indicated full strength in both lower extremities and no neurological deficits. On the date of admission, a pre-anesthesia assessment was performed. Spinal anesthesia was planned with general anesthesia as backup. After multiple attempts at spinal anesthesia by both the nurse anesthetist and the anesthesiologist, spinal anesthesia was aborted and general anesthesia was administered. The surgery was uneventful. Following the surgery, a nurse noted that the patient was unable to wiggle his toes, however no examination was conducted, nor was there any instruction to the nursing staff for heightened monitoring. An orthopedic surgeon saw the patient and reported reduced motor function and nerve dysfunction. Two MRIs were done, a lumbar and a thoracic. The findings of the MRIs indicated possible bleeding on the patient’s spinal cord. Surgery was undertaken to decompress the nerves. Despite the numerous abnormalities noted in both MRIs, the neurosurgeon stated that there was only a small hemorrhage. It was alleged that the defendant failed to advise of the need for heightened monitoring of the patient’s spinal cord due to the multiple failed anesthesia attempts.
Question(s) For Expert Witness
- 1. How often do you administer spinal anesthesia?
- 2. Please explain the proper steps and protocols after multiple failed anesthesia attempts.
Expert Witness Response E-007934
This is an unfortunate outcome. Elderly individuals having neuraxial anesthesia have the highest risk of epidural, spinal, and subdural hematomas. The increased difficulty and the immediate post-op anticoagulation that was provided here all increase risk for bleeding. Therefore, there should have been VERY close followup of this patient. Evidence suggests that early intervention in these hematomas is necessary to prevent permanent deficits. I regularly and routinely provide anesthesia for the sort of procedures described in the case above – often several times a week. This patient should have been on regular 1-2 hour neurology checks to ensure normal examination. Any deficit should prompt an immediate neurosurgical consult. I have never personally had a spinal/epidural hematoma but have cared for patients for whom this was a concern, and we heightened surveillance in order to prevent this sort of negative outcome.