The worst medical-legal dilemma for any physician is to be held responsible for producing devastating impairment and disability in a patient after performing an apparently standard and uneventful procedure.
This problem is not uncommon in the field of anesthesiology. Most anesthesiologists continue to be unaware of the circumstances under which this occurs. None of the material which follows is taught in Anesthesiology training programs (but needs to be). Burton Report presents two basic areas of concern which have become evident, not through, continuing education, but through medical malpractice suits.
1. Severe sudden neurologic impairment following standard epidural anesthesia.
2. Progressive patient impairment following attempted blind needle technique injection of epidural steroid.
First Case Scenario
It is typically not appreciated that a minor event can tip a precarious balance when underlying and unrecognized serious pathology exists with no associated clinical signs or symptoms. When insult to the nervous system occurs slowly over a long period of time the ability of this system to continually accommodate to this problem is legend. If the insult continues or if the fine existing balance is upset clinical problems then become evident.
A classic example of this is the individual with a large benign intracranial or spinal tumor which has been continually increasing in size over many decades. Because the change has been gradual the brain and spinal cord has progressively decreased in volume but the person has remained without any symptoms until this balance is compromised. The event can be minor such as being struck in the head by a basketball during a game, etc., but the person is rendered immediately unconscious, paraplegic, etc. and may even die. In a situation such as this there is little doubt as to the cause of death. In the Burton Experience many cases of asymptomatic lumbo-sacral adhesive arachnoiditis are converted into being clinically disabled by an aggravating factor such as trauma (i.e. motor vehicle accident) or an additional spinal operative procedure adding blood, as foreign body, into the subarachnoid space.
A number of medical-legal cases involving routine epidural anesthesia as a concomitant to labor and delivery have now been identified where the anesthesiologists were held as being guilty in causing the patient’s severe subsequent neurologic problems. In fact, the only role of the epidural anesthetic was to “tip” a pre-existing delicate neurologic balance. The following case is typical:
Standard epidural anesthesia performed under labor and delivery. Patient noted to have a “high spinal” but delivery was otherwise uneventful. Following delivery urinary incontinence and perineal numbness were noted. The patient developed permanent sacral problems with some peripheral weakness. Post-delivery MRI studies showed lower thoracic pathology consisting of cystic cavitation of the conus medullaris and extensive thick scar tissue surrounding the spinal cord in the subarachnoid space.The cystic cavitation of the conus medullaris is shown with the red dot and the spinal cord surrounded with scar tissue is shown with the green dot.
A medical-malpractice case was brought against the anesthesiologist who was accused of injecting the anesthetic agents into the conus medullaris and thus causing this patient’s problems. Even though there were “expert” witnesses found who supported this belief the actual situation was a classic example of the Foix-Alajouanine Syndrome (FAS) where the anesthesiologist was only the scapegoat of ignorance. Typically, the etiology of the FAS is a congenital arterio-venous malformation. In the case noted above angiography of the spinal cord, which was not performed, would have clarified the diagnosis. There was a surgical attempt to “drain” the spinal cysts. Biopsy only of the surrounding dense adhesive arachnoiditis was performed. Despite the fact that the anesthesiologist was blameless the case was settled out of court. Other, similar cases of FAS have also involved medical-legal claims against blameless anesthesiologists performing epidural or combined spinal-epidural anesthesia using atraumatic needles. Paraplegia, paraparesis and sacral syndromes (bowel and bladder dysfunction, etc.) are frequently reported. Rarely is the existence of underlying, long-standing neuropathology suspected and the appropriate diagnostic studies (other than MRI imaging) are typically not carried out. This is not to say that direct intra-spinal injections do not occur. These are well documented in the literature but not usually as the result of anesthetic procedures.
Second Case Scenario
The Burton Experience in Forensic Medicine indicates that the overwhelming majority of medical-legal cases in regard to ill-advised epidural steroid injection (ESI) involve anesthesiologists and this area represents an increasingly large part of all spine-related suits. When numbers of such cases are studied the following factors emerge as being “key determinants” regarding this situation:
Anesthesiologists actively seek activities that place them in direct patient care.
The field of “Pain Management” is thus attractive to anesthesiologists but training in spine care or pain management is typically not part of anesthesiology training.
Procedurist reimbursement is relatively high.
Some pain management clinics are simply “procedure mills.”
Many anesthesiologists mistakenly believe that the “blind” needle approach to the epidural space is accurate.
Anesthesiologists are not trained in the utilization of x-ray monitoring equipment and tend not to use it.
Anesthesiologists routinely perform epidural and spinal anesthesia with basically “safe” drugs and thus have a cavalier attitude toward the handling of potentially toxic substances.
Many Anesthesiologists know little about spine care in general or the chemistry of steroid suspensions containing ethylene glycols.
Most Anesthesiologists have no familiarity with the disease entity “adhesive arachnoiditis.”
It is rare for a Anesthesiologist to ever see a patient after a procedure is performed to provide them with direct information regarding a patient’s progress.
Because of the above Anesthesiologists are particularly susceptible to being guilty of the “The New Guinea Syndrome.”
Anesthesiologist Performed “Blind” Epidural Steroid Injection With Depo-Medrol® The procedure described below is something which is being repeated throughout the United States on a daily basis. This patent underwent a series
of injections, some of which were “wet taps” followed by intrathecal injections of blood intended to be a “blood patch.”
Some anesthesiologists have attempted to defend the practice of “blind” ESI with glycol- containing steroids as being a “Standard of Care” in the community. While this practice may be “common” among anesthesiologists it is not common among their more enlightened procedurist colleagues. A “Standard of Care” can never be something known to be injurious to a patient. Ignorance of consequences is not an excuse when the medical and scientific community have clearly identified the patient risks.