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SNI Digital, Innovations and Learning, a 3D Live video journal, which is interactive with discussion. In association with SNI, Surgical Neurology International, a 2D Internet Journal, is
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pleased to present another in the SNI Digital series on controversies and spine surgery This program was presented on December 27, 2024.
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Nancy Epstein is the person presenting this lecture. She's the professor of clinical neurosurgery at the School of Medicine at the State University of New York in Stony Brook.
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And she's the editor-in-chief of Surgical Neurology International.
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The first talk in this two-part series
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is entitledLessons from Malpractice Cases
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in Servical Spine Surgery. For today's series on controversies in spine surgery, again, we have Nancy Epstein, who is a professor of clinical neurosurgery at the School of Medicine at the State
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University of New York in Stony Brook She's the editor chief of surgical neurology, International, has had an extensive experience with spine surgery going back 40 years and has probably one of the
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highest rate of publications in regard to spine surgery cases in the world. So Nancy, you're going to talk today about lessons for spine surgery from malpractice cases. That's right? That's right
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And I'm also going to emphasize to everybody that. especially if there are any lawyers who who check into this that all cases are actually d identified all these cases are like gun ah so there should
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be no documentation other than there's one case where we definitely had permission from the patient to well reveal some of the information including the diagnostic studies as well as one of the other
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lawyers and one of the other cases gave US permission for monetary reimbursement information but the main thing for today is you know hey you can see on the cartoon here the doctors ready to maltreat
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you now you know this is lessons learned from these malpractice cases to try and improve the medicine the neurosurgery that we're delivering to our patients because it's still all about the patient
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and how we can improve patient care I and the only way to do that is to do it honestly and in a straightforward fashion and confront any of the mistakes or errors that are made I'm gonna just briefly
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go over cervical anatomy. Jim and I have done previous presentations of cervical and lumbar going over the anatomy in greater detail. This is just to give everybody a quick refresher course. I'm
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then going to introduce an unnecessary procedure. Epidural steer injections are actually not FDA approved and they have no document long-term efficacy but they're being done. And in many instances
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really acquired by many insurance companies before surgery is approved and I'm going to tell you one of the major complications arising from that. Another case just representative of unnecessary
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surgery being done but also operations unnecessarily and wrongly being done in the ambulatory care centers and that there are criteria for operating in those centers where you don't do operations with
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patients with major comorbidities in these settings. You do them in a hospital. Then I'll review four cases of negligent cervical surgery. the surgeon actually took a bite out of the spinal cord.
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Surgeon pissed into trial space or into the cord. A surgeon did a wrong level, multi-level, anterior discectomy infusion where OPLL required a multi-level core pectomy. And another case where the
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surgeon actually did a multi-level core pectomy for OPLL, but had no plan to deal with the CSF leak that they should have anticipated based on the pre-OPCT. And what I'm going to emphasize here is
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that five out of these six cases resulted in quadriplegia, and one of the patients died. Wow.
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So these are major cases.
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These are not minor perturbations. This is not questionable of a focal radiculopathy. Just to remind you, you're looking at an AP view of an image of a cervical spine. You've got the vertebral
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bodies, and then you've got the transverse foraminin. The vertebral arteries are going to come through here, and next to it you have an axial view the virtual body itself the spinal canal
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containing the cord here you have the Lamina on both sides Ah you have the Spanish processes where they joined together and obviously by you have your facet joints and again don't forget your
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retrieval arteries and those transfers for amateur and that's why certainly with your C T scans you want to know how wide that canal is the distance between those are virtual arteries to make sure
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you're not off center and going right into one in terms of the anatomy again here let's add some of the soft tissues you've got the vertebral body anteriorly circumferentially you have the epidural
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space here the inter Epidural space followed by the Dura containing the spinal cord followed by the post your Epidural space and then posteriorly you're going to have the Spinous processes and Lamina
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Inter operative Monitoring essential critical. When I was president of the cervical spine research society in 2001, I had looked at a series of cervical cases but done both in New York state as well
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as California. And the one commonality is quadriplegia resulted in 60 percent of those cases was due to a one-level discectomy infusion. It was not just the multi-level complex procedures So again,
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I'm just emphasizing to people, consider using intraoperative monitoring for those one-level operations helps keep you out of trouble, helps keep the patients safer. Why not use something that's
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going to improve patient care?
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Well, maybe because you don't want somebody watching over your shoulder but if you need somebody watching over your shoulder to tell you when you're getting into trouble, basically it should be
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something that you use. Antirely in the cord, you're going to deal with with motor evoked potentials posteriorly. This amount of sensory about potentials and then you have the nerve roots on either
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side. So that's where your EMGs are going to come in. Again, if you just look at these soft tissue of the cord itself, anteriorly, you've got motor evoke potentials posteriorly, you've got some
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kind of sensories and then you've got the nerve roots. Now when the nerve roots EMGs for the motor root anteriorly and the SCP for the posterior root, well guess what? When you try and do an
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operation from behind, especially when you're taking out a disc posteriorly, you may see that there are two separate roots. The anterior root is often white and it doesn't have
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a dural encompassing it. And don't take out that inadvertently, thinking it's a cervical disc because it's not. It's your anterior motor root, may not have a dural investment, so be careful.
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Okay, so let's talk about the first case. This was an unnecessary cervical epidural injection, done a relatively young patient. She had a normal MR, she had a normal neurological exam, okay?
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The epidural, typically these take just three minutes. It's amazing, you can read through the charts, bam, they're in there, they're out. Interventional radiologist did the procedure, left the
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facility within minutes, okay? In the post-operative care unit, the patient complained of severe pain and the onset rapidly of numbness, tingling, and weakness was largely ignored for several
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hours Ultimately, though, the patient was transferred to a hospital, the MRI scan took time to get huge epidural clot being shown, and I'll show you an example of that, but not the patient's
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specific films. Surgery was delayed, why? Because the surgeon wanted to watch to see if the patient was going to get better, was going to, quote, observe the patient. Finally, the patient was
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completely quadriplegic and then he operated and then post-op the patient essentially remained quadriplegic This case ultimately settled. Lessons learned and included avoid unnecessarily of
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performing epidural injections. And if after these epidurals, patients develop deficits, get a timely MRI scan and bring them to surgery in a timely fashion. This is just an example of what a
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posterior epidural hematoma can look like on an MRI scan. And you can see here a cephalide caudad anterior to posterior. Here's C2, 3, 4, 5. Your posterior epidural hematoma massive is sitting
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right here. This wasn't the patient's films, but it's similar to the films that this patient had.
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Just to remind everybody, the MR scans for cervical discs, you can show an anterior interlateral disc, which is appropriate for an anterior discectomy infusion. And here's an MRI scan, a large
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anterior and interlateral discal component here should be done from the front. You're not going to get this safely from the back Okay, but you also have foraminal. his creations as illustrated here
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and you have lateral phenomenal disk as illustrated here Lamina from monogamy should be your procedure of choice here some may do an anterolateral approach as well but just remember you do a lamina
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from anatomy you do not have to do effusion you are not going to encounter a carotid or a juggler vascular injury you still can get into the vertebral if you go out lateral enough you're not going to
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encounter typically a CSF leak which is much more frequent from anteriorly and you're not going to have all those Lotta nerve Palsy recurrent laryngeal nerve palsy making your patient a horse getting
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the Phrenic nerve paralysing the diaphragm getting the sympathetic chain and ending up with the Horner's syndrome getting the vagus nerve etc the list goes on and on for the entire complications so
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here's an example of what a C T scans going to show you ventral spur seen Hiller on your illustration and this is what it can look like on your non contrast C T exam and then here's just an example on
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your mindless E T where here you have your answer or lateral component were more lateral and for rational and this is perfect for doing a lamina from monogamy because here's your Lamina you do a
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meteor fest attacked me you do a lamina from monogamy you can actually visualize that nerve root you can put down biting correct underneath that nerve root picking it up with a bold tip to sector and
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do a really good job by the way if you try and do these anteriorly oftentimes you're going to miss the most for animal component especially if there are multiple burst fragments plus you're not going
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to have to do a fusion well again when you bill you're going to build less and that's maybe one of the Unfortunate motivator back motivating factors here's a second case this patient also had an
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unnecessary procedure but this was an unnecessary anterior discectomy and fusion okay the amour was normal the patient had known no indication for doing this operation There were multiple medical
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comorbidities and the medical co -morbidities are contrary indication to doing surgery in an ambulatory care center so is typical for older patients with major co -morbidities this patient was
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morbidly obese and additionally to that diabetes hypertension alcohol abuse sleep Apnea C O P D and other factors can contribute to that but especially the morbid obesity and big contraindication to
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don't do it in the air se because guess what you're not keeping these patients overnight you're not watching them for a day or two to anticipate all the complications that they can get into so
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ambulatory care center Guess what this case was done very much very late in the day they just observed the patient for two hours the minimum required is four to seven hours this patient should have
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been transferred to another institution to a hospital patient by the way got home severe pain instead of numbness, tingling, weakness, within two hours that patient was dead. And the patient in
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this case died of a hematoma. So here the lessons learned is again, avoid unnecessary surgery, not only the unnecessary procedure, which was the epidural I just went over, but avoid ASC in
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patients with major comorbidities. So here's just an illustration of a postab wound hematoma, which is what this patient died from. By the way, if you're in any facility, and your patient after
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an ACDF suddenly develops shortness of breath, swelling of the neck, red blood coming from the drain, open the patient right then and there, and then bring the patient back to the OR and
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re-operate. Don't hesitate, don't delay, and don't bring them down for a scan at that point, just re-operate, okay? Because otherwise you're gonna have outcomes like in this patient, which was
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an extremely unfortunate situation. Okay, so case three Well, you see a pituitary over here. When you put a pituitary into a disc space, cervical disc space, lumbar disc space, you know, you
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wanna put it in closed and then you wanna open it up and then you wanna close it again. You don't wanna put it down too deeply. I can remember as a kid in kindergarten, my best friend had a lumbar
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disc herniation done in the state of California. Her dad was like in his mid 30s. They got into the aorta and he died Why? Probably because exactly this. They had the pituitary in there. They
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opened it all the way. They went right through the annulus and right into the aorta. Well, in this case, what they did, and I'm showing you a bite being taken, a non-spine surgeon did a
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multi-level ACDF just one day, had not done very many in his career, okay? He literally took a bite out of the spinal cord. We know that because that's exactly what the resident at that award
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table stated in his deposition. It's not in the OR note, but that's not a surprise. This patient woke up quadriplegic. Yet the surgeon made sure that there was no stat post-operative MRI scan and
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no re-operation ever done on this individual. Patient remained a quadriplegic and this case settled. But lessons learned here, again, spine surgeons shouldn't be doing the spine surgery or spine
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surgeons should be doing the spine surgery Non spine surgeons should not. And really, it's best to always tell the truth. Surgeons who create fictitious operative notes and try and really nearly
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change their depositions, big mistake because guess what? There are other people in that OR, including your first assistant, who are gonna tell the truth. And in this case, the assistant said,
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I remember that patient jumped almost to the ceiling as soon as that bite was taken.
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also postoperatively do what's right for the patient and is this a new deficit to your status more seated yes Tim communication is immediately largest there's no point going through anything else is
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just going to wind up in the same situation but worse yeah this this case actually went through I everybody's deposition before it they finally settled and it was really and if the patient was
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obviously devastated
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this was another case the surgeon pissed into trial spacer into the spinal cord okay there was no interpretive Laura lateral fluro imaging as was required based on the instructions as to how to use
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this instrumentation system and I'm going to show you that briefly there was no spine I pushed them so that the people in other countries were route he means It means you're plunged further into
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exactly it's like taking a knife and just stabbing somebody okay this this was this metallic device was literally not just placed into the disk space because there was no ladder or floor but it was
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basically plunged right into the spinal canal where a damaged the cord post -op the patient was quadriplegic again no studies were done no re operation was done and the patient remained quadriplegic
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and this case settled and the lessons here were tell the truth like we just spoke about and do what's right for the patient get a stat and more and re operate if you can in this case a re operation
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would likely have consisted of doing a multi level Laminectomy just so that the patient had some room to swell into OK but this is emphasizing that surgeons must be familiar with the products that
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they're using in this case the manufacturer in their insert said warning trial spacers do not have a depth stop an image intensifier should be used to visualize and check the position during insertion
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in this case nowhere in the operative note was there any mention of having used that image intensifier or fluoro while this device was being placed one of the experts later brought this up and it was
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then communicated back to the surgeon who then came back and said oh yes of course I use this and I just didn't put it in there because it's just routine well nobody actually believed that but these
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are the devices that are used they have slightly summer or green blue purple yellow because of the different shape once hyper Lord Dodik ones Lord Dodik runs parallel to the end plates and one's
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convex so they're different shapes in different sizes that are used and basically this is where it's pissed and or pushed right into the disc space and Here's your a P view here and here's your
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lateral view but that's where it's supposed to stop but it was saying is that the device itself does not have an automatic device in there to make sure that you stop short of going into the spinal
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canal so that's exactly what happened in this case and again it emphasizes that when you do an AC dia for one level or a multi level you're going to do your anterior discectomy and fusion but post
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yearly you should have safety ridges that are there posts yearly to prevent any pistoning of any interbody device much less you know in this case you know your trial spacer and
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so many people constantly are asking if you're doing a multilevel cervical operation you know what what are you using to determined do you go anteriorly or post yearly and one way of sort of
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collecting together all the impressions is to use something called the K line but it's going to incorporate, as you're going to see, lordosis, hyper lordosis, kyphosis, et cetera.
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So if your pathology is anterior to the K-line, and the K-line, by the way, is a line that's vertically drawn between the mid-aspect of C2 and seven, okay? But with a positive K-line, you can do
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anterior posterior 360 surgery, whereas if it's behind the K-line coming from anteriorly and you've got kyphosis, you're going to need anterior surgery So this is just a way of repeating exactly
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what I'm just saying now. Here's your positive K-line. That's the line, mid-C2, down to mid-C7. You're going to draw it on every patient, okay? Sometimes it's going to come outside the spinal
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canal. But this is just emphasizing that your pathology, in this case, is in front of that line. So this is the positive K-line sign. Here, the negative K-line. Here's your K-line, same K-line,
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mid-C2 to 7. your pathology goes behind that K-line. So basically it's telling you, okay, you wanna get this pathology and look at the kyphosis here. There's lordosis over here, but kyphosis
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here, you're gonna probably have to go in here. Okay. So if you have a positive K-line, the safest choice is to do a posterior operation for all the long list of complications that I've, or
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adverse events that we've just described for doing an anterior procedure With a negative K-line, you're likely going to have to go anteriorly. So again, positive K-line, a good lordosis, anterior
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posterior 360
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surgery, but choose posteriorly when we can because it can be the safest choice. The negative K-line with the kyphotic patient, you're likely going to have to go anteriorly. So here, just to
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re-emphasize, you have a positive K-line. All this pathology is in front of this K-line, mid-C2 to 7, okay? You're gonna do a laminectomy. Here's your laminectomy. That's where your K-line was,
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but here your spinal cord is gonna move anteriorly away from all these ventrally situated osteophytes. So the pathology here remains, but your cord migrates nicely away from it, okay? Here, on
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the other hand, you have the negative K-line where here's your K-line, basically. And what happens here is that that biphatic deformity is gonna go right behind that And you're not gonna get any
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decompression if you do something from behind, 'cause the cord's gonna be tethered over the anterior disease. It's just as if you take your finger and you pull a rubber band over your finger, okay?
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Your finger is preventing that rubber band from straightening out.
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Very good explanation, really good.
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Okay, so here, again, anterior K-line. Here's your OPLL pathology here, hypothetically, or any pathology, anterior to the green line.
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Okay, here, the MRI scan shows multi-level spondylosis. Here's your K-line or where it would be. Do a posterior operation because guess what? You've got an excellent lordosis. Here is a CT scan.
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It's actually a Milo CT scan. You can actually see the die. But here, great idea. There's your K-line and do a posterior operation because again with that lordosis, you remove the posterior
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material, the laminar, spanish processes, et cetera You're gonna have plenty of room for that cord to migrate away from that anterior pathology. On the other hand, you have a negative K-line.
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Here's your kyphosis, okay? Here's, I'm just figuratively drawing in a lot of anterior pathology and then there's your K-line. So it's clearly going behind that line and you have a kyphotic
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patient. So here's an MR, a little hard to see. Here's your K-line.
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That hypo-intense material on that MRI scan, happens to be multi-level OPLL. And why do I know? Because if you look carefully, it is not just opposite the disk spaces, but you see how here, this
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is C3. It starts midway up C3 and goes all the way down here, almost like C5-6, but do you see that behind the body, particularly of four, all that hypo-intense material is there? So the OPLL
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continues behind the vertebral body And here is the CAT scan of a similar finding. And again, you can see the K-line that's drawn in here, a little more difficult to see perhaps, but here C2, C3,
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C4, and here you know, you can do an anterior-corpectomy and fusion and basically decompress things. And if you do the axial image on these and you draw your K-line, you're gonna see a huge hunk
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of that OPLL is behind that K-line. You are not gonna get that out from behind. You are not gonna decompress that patient by doing a posterior operation.
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Preoperative CAT scans are very important to get in patients with cervical disease, especially if you in any way suspect ossification of the posterior longitudinal ligament. And these are the three
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dural signs that you're gonna see in many of these cases. This is what's called the single layer sign. It can be continuous with the posterior aspect of the vertebral body and it can be a huge mass.
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It's gonna vary in size, a single layer sign Years ago, I described what's called the C sign, so you have a single layer of material, but you see the way it's going off to the side and here you
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have a C because Dura becomes imprecated in this. If you try and go for this from anteriorly, or you have to go from anteriorly, be anticipating a CSF because very likely you're gonna get one. And
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certainly use a microscope. It's just absurd in cases where they don't. These, on the other hand, are two double layer signs and what do they have in common? You see, the posterior aspect of the
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vertebral body, and then there's a hypodense line. That hypodense line, that is your dura. So all of this other material, this hyperdense material is intradural, and here, same thing. This is
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your dura. This is hyperdense OPLL inside, calcification inside your dura. There's no way you're gonna decompress that without having a massive CSF leak. You have to anticipate it and be ready to
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treat it from the get-go, and these are patients where I'll show you later. You have to do a prep and drape from the get-go with anticipating that you're going to do a wound peritoneal shunt and a
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lumbo peritoneal shunt.
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So here is a patient over the age of 65, and this patient was diagnosed by a non-spine surgeon as having multiple discs on an MRI scan. Oh, by the way, this surgeon had never done a corpectomy.
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So I'm preparing you He's going to do a multi-level discectomy. He did not obtain any preoperative CT scan because he didn't realize that this finding on an MR is consistent with OPLL. So he had no
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diagnosis and no anticipation that OPLL would be present. He certainly never spoke to the radiology who radiologist who in this case was a neuro radiologist who questioned whether or not there may be
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OPLL. These are not the exact images of this patient. But you can note that that OPLL mass that I'm showing you, hypointense, okay, some of it comes behind the K line, and you can see that
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there's very hyperintense change in the cord itself here. So again, this is what you're going to see on the MRI scan, okay? The surgeon diagnosed discs on the MR, again, a non-spine surgeon.
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There was no CT, no pre-op diagnosis or anticipation of OPLL. He did the wrong operation, a multi-level anterior dyspectomy infusion. Look at what that's going to do Just take this level for
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example. All of this OPLO is back here. Before you know it, the surgeon's going to find himself intradurally and inside the spinal cord by mistake. And some will end up with anterior spinal artery
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injuries as well. But to do a multileveled discectomy here, here, and here, guess what? You're leaving all of this disease behind the vertebral bodies. I've seen some surgeons claim, oh, well,
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I just use an upright in curette. I get behind the body and I can remove it. Doesn't work Gets a mass of CSF leak and typically damages the cord. But in this case, leaving that residual OPLO
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behind this body, behind this body, somewhat behind this body, stretch the spinal cord over the residual OPLO and post-op the patient was quadriplegic. Again, recurring image, recurring problem.
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No post-op anymore, no re-operation, and the patient remained a quad. This happened to be an eight-figure settlement, so we got clearance to state that.
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So what did that patient really need? Patient needed a multilevel anterior corepectomy infusion. An anterior corepectomy, in this case, would have freed the cord from the OPLL. And here you can
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see the corepectomy graft putting from here to here C2, C3, 5, 6, 7, down to T1.
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Okay. But no, did a multilevel anterior discectomy infusion and the purple is supposed to be the OPLL left behind those vertebral bodies during that dissection. Might have gotten out some of the
29:01
OPLL at the levels. Actually, typically they go in, they almost immediately get a CSF leak and then they start to back out. If they're smart enough to have intraoperative monitoring present, the
29:12
intraoperative monitoring also drops out. And that tells them that they're doing the wrong operation. What you should be doing at that point converting to a multilevel corepectomy. not just a
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discectomy. And the other mistake they make is, oh, they go, they do the multi-level, they do one level at a time, they do
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a discectomy here, and then they put in a graft without completing decompression and dissection of the OPLL at the other levels. That's not even worse, because then you're stretching the cord,
29:43
making it a schematic and pulling it over, OPLL that has not even been removed yet. So these are the sequential mistakes or errors that are made in these cases, but stretching the cord over the
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residual OPLL, in this case, certainly was responsible for severe quadriplegia. Can you go back and let me ask you a quick question? Yeah, sure. You know, I'm sitting here thinking about, you
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see OPLL in the calcification of
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the duro, that's what's happening, right? Right. And you see that the cervical spine, you don't see it in the lumbar or thoracic spine. Am I right about that? You see it, you see it, but less
30:20
frequently. The order is cervical, followed by thoracic, followed by lumbar, but you can get significant opioids, thoracic spine as well. It's just, what causes that, is it,
30:33
what's it? It's genetic, it's just, yeah, it's genetic. It's genetic. Okay. The HLA side, et cetera. There have been lots of hypotheses, it runs in families. It can occur sporadically,
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obviously, but very high prevalence in families. Interesting, okay.
30:52
So in case five, it's an example where a multi-level corepectomy, this is what should have been done. Okay, you do a multi-level corepectomy, you put in
31:00
a strut graft, and then you put in your anterior plate. I can remember doing a corepectomy earlier. This was in the early 2000s. We did release C2 down to T1, and
31:13
we had to have Asculab send us stat, a plate that they hadn't even released yet. It was the longest plate that they had. It was a dynamic plate, and we placed that anteriorly, and then you can do
31:27
a multi-level posterior fusion. If you're doing a two-level intercorpactamine fusion, you need to do a posterior fusion, because the rate of that two-level corpectomy extruding is about 20. If you
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do a three-level or more corpectomy, and you do not do a simultaneous posterior fusion, the rate of extrusion is about 50. I wrote an article on this back in 1998, and Alex Picaro also read an
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article on that as well. So again, circumferential surgery really comes into place with these multi-level corpectomies. So here is another case, middle-aged patient. Multi-level OPLL, did the
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both the MRs and the CT scans, had a negative case, I decided to do multi-level anti-corpectomy infusion, had not done many, but it was from C3 to C6. Now, they did have a CAT scan, and the CAT
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scan showed clearly. that OPLL was to and through the Dura, but they failed to plan and anticipate that interoperative CSF leak. And now why I'm saying anticipate, 'cause I'll show you shortly,
32:31
they wrongly treated this leak with, oh, they threw in a chunk of, you know, lyophilized Dura, and then they put Dura Seal anterior to the spinal cord. Now that's one of the main
32:43
contraindications for its use because it caused a huge compressive mass I think also during this operation, they just directly damaged the cord during the core pectomy. But in any case, this
32:55
patient postoperatively was quadriplegic. The patient has, these are like, like what the patient would have had preoperatively, the multilevel OPLL seen on the CT, as well as here on the MRI scan
33:09
with a high signal in the cord, seeing particularly at the three, four, and four, five levels. Okay, so now I'm just gonna show you because we actually brought this up. We did get permission.
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to show the postoperative CAT scan in this case. And here you can see the postoperative CT. It shows a block of material C3 down to C6, okay? But guess what? A STAT CAT scan is gonna show you the
33:33
bony information. It's not gonna give you enough information as to what's happening in the canal. It might show you that the graft is extruded into the canal, but it's not gonna show you any
33:42
changes in the cord. You really need to do an MRI scan to get that information So in this case, they did an MR. It was delayed for many hours, okay? And this is the actual MR scan and look at
33:57
that. That is your anterior derral compression. That is your anterior duroceal. Now the radiologist correctly read that as showing massive anterior compression. And you can see how the cord is
34:07
displaced posteriorly. Your compression is anterior. It's not posterior, okay? But the surgeon wrongly did just the laminectomy, okay? Post-op and leave the patient remain quadriplegic. did not
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repeat the MR, did not re-operate, and
34:21
just left that anterior dursial in place. The patient remained quadriplegic, and this was actually a seven-figure settlement. This was actually during COVID.
34:32
But in this case, really your radiologist was laying it out for you, where the problem is. Go back, take it out. But, you know, he had the severe leak and didn't know how to deal with that.
34:44
What should really have been done in this case is the surgeon should have anticipated that there would be a huge intraoperative CSF leak. Then, when you're doing the operation, you can prepare and
34:54
drape. See, the incision is marked here. And the, you know, right over the liver, you're drawing where you're going to put that catheter. And here, I already, you can already see the dotted
35:06
lines. Dot lines are gonna go, you know, the subcutaneous spacer is gonna go right underneath here, and you're gonna go down to the peritoneal cavity, and you're gonna put in a wound. peritoneal
35:18
shunt intraoperatively. That's what should have been done here. Prep and drape for that wound peritoneal shunt. And then postoperatively you can put in additionally a lumbar drain or you can decide
35:30
to do an immediate lumbar peritoneal shunt. The problem is if you put in a lumbar drain, still that patient is still going to be probably using that lumbar drain rather than the anterior drain
35:40
itself. And a lumbar peritoneal shunt placed immediately was the way I basically ended up doing these And you have to use a horizontal vertical valve, where every time the patient stands up, the
35:51
pressure will go way down and will end up with a subdural. But this is one of the old uni shuns that we used to use. There are many other shunt catheters that can be used. Now you can track the
35:60
shunt catheter directly from your neck exposure to the abdomen and always put that dome of that shunt catheter near the anterior incision so you can always tap it to try and confirm is it open,
36:12
closed, et cetera I ask you a question. I don't know if this is sensible or not, but here I am at surgery, and I'm concerned that something's happened to the operative space and so forth. I put
36:29
this stuff in there, one to know, is there any way of injecting some radiographic dye locally and taking a lateral portable spine? I know what that's going through the surgeon's mind. Yeah. I got
36:41
to get an MRI right after surgery, and it's lined up and they got a weight and it's anxious moments. Is there anything you can do to image it immediately? Me too, to image the extent of your CSF
36:55
leak because if you
36:59
put your - Let's say you got CSF coming out of the inject. You inject dye in the area. I mean, it's gonna go many places, but if it gets into this spinal fluid and surrounds the cord, at least
37:09
you get some image you would know. Is that a wild idea or not very good? been used in some cases. I mean, the fact that, you know, it's just right in front of you. It's perfect doing a
37:22
myelogram. I don't think it's necessarily going to help you in this case because you see the massive CSF leak that's there. You know that you have open dura and your question is, how are you going
37:33
to end up treating that? And you're going to need to do that anterior wound peritoneal shunt. And it's got to be a very low pressure system so that you, you know, there's no hesitation to use that
37:44
as an external conduit And then when you're doing your lumbar drain, actually sometimes, you know, so much CSF has poured out, you're not going to have an easy time getting
37:58
in that lumbar drain initially. But I think using the diantery, I think most people would not use it. You know, you always worry about arachnoiditis, you worry about, in this case, seizures if
38:06
it gets intracranially. So
38:09
I think most of the time we probably wouldn't use it. Okay, good answers. Thank you
38:14
So let's just summarize what we've been talking about. for the cervical procedures. The summary is pretty grim. We have five quadriplegic patients and one patient who died. These are not minor
38:28
procedures. These are not minor adverse events. These are not minor errors. These are major egregious errors. And one of the main factors here is if a problem, an adverse event occurs, do
38:47
something about it.
38:50
Because without pursuing something that might reverse that patient's status, they're going to remain quadriplegic for the rest of their lives. Here, what happened? The unnecessary epidural
39:03
injection? That settled. It settled out of court. But boy, everybody in the world went through the
39:11
oppositions, in this case, and the unnecessary death That case also settled, negligent cervical surgery, took a bite out of the court of the court, that settled. Everybody was deposed, as I was
39:25
once told by a defense attorney, everybody wants to be able to bill. So those lawyers are gonna make sure that everybody in the world is deposed before a settlement is proposed. Surgeon pissed in
39:39
the trial spacer into the court. There were also in some of these cases, a question, did the resident do the surgery rather than the attending surgeon? And the
39:49
wagons really circled around that to protect the residents, even though in some instances, some residents in their ACGME forums might have tested to the fact that they did a major portion of that
40:01
operation. Surgeons doing, wrongly doing, a multi-level anti-dissectomy infusion, especially a surgeon who'd only done one level, a one-level, one-level corpusctomy in his life. And that had
40:16
been in a supervised setting. And that was a case that settled for eight figures. And the other was the multi-level courtectomy where the CSF leak was completely mismanaged. And that settled for
40:26
seven figures. And actually, if hadn't been in the midst of COVID, it probably would have gone to court and would have been many more figures than that. But it's not just that these settle these
40:37
cases. It's not just the monetary configuration. It's what happened to these patients because there was not enough, it's like a mental error in baseball. So many of these errors could have been
40:50
avoided, had the person involved, the surgeon involved said, Hey, this operation is not for me. I'm a skull-based surgeon. I'm a peripheral neurosurgeon. I'm a vascular neurosurgeon. I'm not
41:06
gonna take on doing a spine operation, even if it's gonna be good for my RV usein my institution.
41:14
And then when these adverse events occur, don't just assume it's going to disappear because you ignore it. And don't lie, when your operative reports, a lot of these are templated reports, and
41:27
what's in the operative reports are fiction compared to actually what went on. But other people in the OR are going to know what went on, especially your first assistant, and somebody else is going
41:38
to tell the truth.
41:40
Well, let me ask you a question about this Obviously,
41:46
you've seen a number of these cases. Any of these cases that you know have gone to trial and essentially been dismissed?
41:57
Okay, well, the answer is no, but in case number five, oh, this should have been number six, but anyway, the case that settled for eight figures, that actually went to court for one day, and
42:07
then they settled
42:10
The cases, these cases were not dismissed. These were not defense verdicts. And I know what you're getting at. Like some of these go to summary judgment where they say, well, you know, but
42:21
really in this case, the surgeon should be taken out of the equation because it wasn't their fault. And it's just the extent of the disease and Opiole's difficult operation. And it has a high
42:31
incidence of spinal fluid leaks and neurological deficits. In short, you know, looking for excuses Oh, well, it was just within the standard of care. But the answer is, should quite a plea to
42:43
be within the standard of care? Well, that's my point is that it's at some point and there are different lawyers that get into this. You've already talked about the fact that everybody's looking
42:54
for money. At some point, the surgeon himself
43:01
is really at risk here and you just settle it. And it would seem that that's more reasonable stretching it out, you only antagonize the family or antagonize the other side. The jury is obviously
43:13
not sympathetic toward you, but more to the patient. It would seem reasonable that, yes, I did it and it's a mistake, those mistakes happen, but
43:27
we just have to settle the case. Does that make sense? Yes, it does, but I can tell you that there are so many instances where the insurer comes back saying, you know, look, the doctor has the
43:40
final word here. In some cases that the doctor has no word over what's gonna happen. In other words, the insurer can say, look, their policy doesn't cover this. The policy is that we as the
43:52
insurance agent can choose to pursue it or end it or settle it or whatever. But in other instances, the surgeon has the final word as to whether they settle or not. And if they refuse to settle,
44:04
then they have to, you know. abide by what they're saying. I mean, I remember one case, it was in New York, and I was asked by the surgeon, this was a defendant, you know, he said to the
44:18
insurance company, Look, if Epstein reviews this caseand thinks that I should settle, I'll settle. And I reviewed the case, and it was clear as day that he had to settle, and he did. But there
44:30
are a lot of other surgeons. It's the arrogance and the inappropriateness and the insensitivity as to what they did wrong, or that they did anything wrong, or that they could ever do anything wrong.
44:46
That's what you're up against. The main thing that you're looking at is you have, well, five out of these six cases, quadriplegic patients, and they're waiting for years to have some financial
44:58
relief so that there's a way to take care of them Okay, so So let's say I'm a surgeon and I say, like I made a mistake, let's settle it. Insurance company may have a different approach to the
45:11
problem, is that correct? And one is to take it to court. And they also have documentation that you wait, every year that you wait in a patient who's quadriplegic, there's a certain frequency of
45:23
those patients dying. And at that point, it's gonna cost the insurance company less. Wow. Yeah Okay.
45:38
So, you know, Jim and I were talking about this, you know, how would you have judged these cases? Should these have been, you know, defense verdicts, plaintiff's verdicts, settlements? And
45:48
the other is, what should you avoid in the future to not be in this same position with either a friend or relative or yourself, you know? ordering unnecessary epidurals, avoid unnecessary anterior
46:02
discectomy infusions and performing operations in ambulatory care centers in patients who are older with other major comorbidities. Avoid taking a bite out of the cord. Make sure that that pituitary
46:13
is not open and you're not just plunging in blindly. Avoid pistoning that trial spacer into the cord. Read that insert for that specific product. If there is no stop for that inter-body spacer,
46:26
then you've got to be super careful and use lateral fluoro. Avoid doing the wrong operation. If you need to do a multi-level corpusctomy, and this is not something you know how to do, hand the
46:38
case to somebody who knows, okay? And avoid using duracile. Enter to the cervical cord. This is obviously in the product insert, should never have been used here. Was left in place and left the
46:50
patient with a major deficit
46:54
And that brings us language before surgery. excellent, excellent summary there, and a lot of messages there. One last question before we go to Lumbar. Yeah. And how much power does the doctor
47:08
have to say, I don't wanna go through all this and wanna settle this? Or is this basically 'cause it's a hospital, you've got everybody else into it, he or she can't do that? Well, I think, you
47:17
know, it's, you have often multiple defendants You can have
47:25
a surgeon who may be employed full-time by the hospital, and then they're under the hospital. Many times your neurosurgeons or spine surgeons or therapeutic surgeons are independent practitioners.
47:40
So they are a completely different set of insurers. And lots of times, you know, the emergency room physicians and hospitalists and other consultants may not be full-time employees of that hospital
47:52
So the hospital is often. One of the defendants, but there may be multiple other defendants involved in that case, so it's a conglomerate of people who are involved in terms of making these
48:04
decisions. So it's not their temple? No, but there are some cases where they will drop the surgeon from the case because the surgeon settled, but the case remains against the hospital or the
48:17
internist or the radiologist or somebody else. Okay, good points, good lessons. Nancy lists nine references after these talks. For your records, take a screenshot of each
48:33
slide as it appears for your records.
48:40
Slide 1
48:45
Slide 2,
48:49
slide 3,
48:52
slide 4,
48:56
slide 5,
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slide 6, reference
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6, reference 7,
49:08
reference 8,
49:11
and reference 9.
49:15
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