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TMLT
RISK MANAGEMENT
Delay in diagnosing cervical spine fracture
By TMLT Risk Management Department
This closed claim study is based on an actual malpractice claim findings. Surgery was scheduled in 3 days. However, later that after-
from TMLT. The case illustrates how action or inaction on the part noon the patient was unable to move her legs and was barely able to
of physicians led to allegations of professional liability, and how risk move her fingers. The neurosurgeon examined the patient that
management techniques may have either prevented the outcome or evening, noting a marked quadriparesis with more weakness in the
increased the physician’s defensibility. The ultimate goal in presenting lower extremities and a sensory loss across her upper chest. He pro-
this case is to help physicians practice safe medicine. An attempt has ceeded to perform an emergent anterior cervical diskectomy with de-
been made to make the material less easy to identify. If you recognize compression at the C5-6 level. Although the surgery was performed
your own claim, please be assured it is presented solely to emphasize without complications, the patient’s neurological condition did not
the issues of the case. improve and she remained paraplegic with profoundly weak upper
extremities. She developed a pleural effusion and atelectasis in the
Presentation and physician action left lung and problems with kidney function.
A 79-year-old woman came to the emergency department (ED)
She was discharged 10 days later to a long-term rehabilitation fa-
of a large hospital after falling down a flight of stairs. The patient cility. Her fine motor movement of the upper extremities was mini-
complained of pain in her head and neck. The ED physician noted mal, and deep tendon reflexes in her legs were absent. She had 0/5
abrasions, hematomas, swelling, contusions, and tenderness in the muscle tone in the lower extremities and 3/5 muscle tone in the
neck and upper back areas. upper extremities. While at the rehab facility the patient suffered a
number of complications, and a second cervical (C5-6) decompres-
The ED physician ordered x-rays and a CT scan of the head. Ra- sion was necessary. A PEG tube was placed after the patient suffered
diologist A reviewed the films via teleradiology and read the results a CVA.
as negative. The patient was discharged with a diagnosis of head and
neck pain, cervical strain, and scalp and forearm contusions. The pa- Five weeks later, the patient died due to complications of blunt
tient was given a cervical collar. trauma to the neck, a cervical fracture at C5-6 resulting in traumatic
quadriplegia, and complications of a CVA, pneumonia, and sepsis.
The next morning Radiologist B over-read the films, and con-
cluded that there was a small, non-displaced fracture involving the Allegations
facets of C5-6 that was not well seen on the cervical spine images. Lawsuits were filed against the ED physicians, the hospital, the
Radiologist B called the ED physician currently on duty, notifying
him of the findings. After learning that the patient had not been ad- neurosurgeon, and both radiologists. The allegations against the ED
mitted, Radiologist B suggested that someone from the ED notify physicians included failure to properly determine the patient’s con-
the patient immediately. dition and failure to contact the patient and have her return to the
hospital. Allegations against the hospital included failure to have poli-
An attempt was made to contact the patient, but without success. cies and procedures in place to insure that the patient was contacted
Although the hospital employees were instructed to follow up, the and told to return to the hospital. Allegations against the neurosur-
patient was not contacted. geon involved delayed treatment.
Three days later, the patient arrived at the same hospital by am- The allegations against the radiologists involved failure to properly
bulance. She complained of pain and discomfort in her head and interpret the x-rays and CT scans from the initial ED visit and failure
neck, and was beginning to develop numbness. While in the ED, it to properly communicate the correct results. The plaintiffs alleged
was determined that the patient had a cervical spinal fracture at the that had Radiologist A made the correct diagnosis, timely and effec-
C5-6 level, which had been identified on the CT during the first ED tive treatment could have been initiated earlier.
visit. The patient was admitted, a neurosurgeon was consulted, and
an MRI was scheduled for the next morning. Legal implications
Given the initial missed cervical fracture, it was difficult to find
After returning to her room, the patient experienced a hypotensive
episode and was given a bolus of IV fluids. The neurosurgeon’s physi- an expert who was supportive of Radiologist A’s actions. However
cian assistant examined the patient and noted normal neurological
32 San Antonio Medicine • September 2016
