Failure to diagnose herniated disc

Presentation

On June 10, a 57-year-old man came to a nearby hospital for an MRI of his cervical and lumbar spine. He was experiencing severe acute low back pain, tingling in his left arm and hand, and low back pain radiating to his left leg, to his foot, and into his left groin.

Physician action

A radiologist reviewed the MRI and concluded the following:

“3 mm broad based paracentral disc protrusion to the left at C6-7 without impingement upon the spinal cord or spinal stenosis, and 1-2 mm disc bulging at C2-C3, C3-C4, and C5-C6; severe degenerative disc disease at L5-S1 with marked narrowing of the neural foramina bilaterally due to posterolateral spurs; and prior laminectomy on left at L5-S1 with thickened scar surrounding S2 nerve root.”

Based on the radiologist’s findings, the patient’s primary care physician did not feel surgical intervention was necessary. He prescribed conservative treatment including medication and physical therapy. The patient’s symptoms worsened, and he sought a second opinion from a neurosurgeon.

On July 3, the patient came to the neurosurgeon. Upon examination, he found the patient to be in considerable pain. The patient stated that physical therapy and pain medications did not provide any relief. The neurosurgeon reviewed the MRI films.

His impression was that the lumbar spine showed marked degenerative disc disease and, “Foraminal and extra-foraminal disc herniation at L3-L4 on the left ...” In addition, the neurosurgeon felt emergent surgical repair was needed.

The neurosurgeon called the radiologist who interpreted the MRI. He documented the phone conversation accordingly: “Telephone call ...discussed MRI of lumbar spine ...agreed there was a foraminal and extra-foraminal disc herniation at L3-L4 on left.”

After this phone call, the radiologist completed an addendum to the June 10th note, stating “Study further reviewed after discussion with Dr ...who states the patient has severe left lower extremity radiculopathy. The review of the study shows soft tissue signal at left L3-L4 neural foramen consistent with disc material probably due to a far lateral disc protrusion.”

On July 5, the patient underwent surgery to remove the herniated disc at L3-L4. The patient was discharged the same day. He was seen in the neurosurgeon’s office on July 31 with good results. The patient never followed up with any further symptoms.

Allegations

A lawsuit was filed against the radiologist, alleging that he negligently interpreted the MRI study causing the patient to be improperly treated on a conservative basis. This 22-day delay in diagnosis allegedly caused the patient increased morbidity/injury, pain and suffering, and a less than optimal postoperative result.

Legal implications

The plaintiff’s neuroradiology expert was critical of the radiologist’s failure to diagnose a disc herniation at L3-L4 on the lumbar MRI. He was critical that the radiologist called what he saw a “L3-L4 bulge” instead of a herniation. He also testified that the delay in diagnosis caused the patient’s current problems.

Defense experts, including the patient’s treating neurosurgeon, said the radiologist did not deviate from the standard of care in his interpretation of the MRI. The MRI was very difficult to read because of the patient’s prior surgery. The neurosurgeon testified that it was after he correlated the patient’s symptoms with the MRI films that he diagnosed the L3-L4 disc herniation. In addition, the patient fully recovered and there was no permanent damage that could be tied to any alleged delay in diagnosis.

Disposition

This case was taken to trial and the jury returned a verdict in favor of the defendant.

Risk management considerations

In reviewing this case, one defense expert stated “Unfortunately, radiologists do not have the benefit of directly examining the patient clinically.” While radiologists are supplied with a patient’s basic history, the defendant did not have the ability to clinically correlate the patient’s symptoms with the radiographic findings.

Regarding documentation, the radiologist appropriately added information to the medical record after his conversation with the neurosurgeon. Late entries or addendum are allowed in the medical record only with proper identification and the reason for the delayed entry. The entry should be clearly labeled as “late entry” or “addendum” with the date it was done and a reference to the date concerned.

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