Failure to properly administer an epidural steroid injection
by Olga Maystruk, Designer and Brand Strategist, and
Karen Werth, MBA, CPHRM, Lead Risk Management Representative
Presentation and physician action
On June 15, a 32-year-old man visited his primary care physician with reports of neck and upper back pain radiating to the left arm. These symptoms emerged after a motor vehicle accident four years earlier. The patient had a history of anxiety, depression, insomnia, migraines, tremors, and hives. His medications included duloxetine, levocetirizine, lorazepam, montelukast, and zolpidem.
X-rays of the patient’s cervical spine demonstrated flatback syndrome, moderate degenerative disc disease at C5-C6, and mild spondylosis. He was referred to a rheumatologist.
On September 10, the patient came to a rheumatology clinic with reports of hand, elbow, shoulder, and intermittent neck pain with left arm neuropathy and significant radiculopathy causing headaches. The rheumatologist ordered an X-ray, ultrasound of both hands, and various laboratory work. The ultrasound revealed mild active non-destructive inflammatory arthritis. The physician prescribed gabapentin and referred the patient to a pain management specialist.
Two days later, the patient was seen by a pain management specialist. After reviewing results from the cervical spine X-ray, the physician’s diagnosis included cervicalgia, cervical region radiculopathy, cervical spondylosis, and cervical muscle spasms. The pain management specialist performed a left C6-7 cervical epidural steroid injection (ESI) and recommended physical therapy, therapeutic exercises, transcutaneous electrical nerve stimulation, and strengthening.
On October 14, the patient returned to the pain management specialist with reports of cervical spine pain radiating to the upper right arm as well as stiffness, numbness, and tingling. The patient reported his symptoms had improved by 30 percent after the ESI in September. The pain management specialist recommended a cervical MRI without contrast and physical therapy.
Before those recommendations were fulfilled, the pain management specialist performed a second left C6-7 cervical ESI. The procedure was noted in the records to have gone well with no adverse effects. However, the patient reported to subsequent treating physicians that he had involuntary movement (“jerking” of the left arm) and severe stabbing pain during the procedure.
On November 3, the patient underwent a cervical spine MRI which revealed a multi-level uncovertebral joint hypertrophy with disc protrusions on the left side at C5-C6 and C6-C7, and a syrinx at C6-C7.
The patient continued to experience pain, numbness, and limited use of his left arm.
Allegations
A lawsuit was filed against the pain management specialist alleging failure to:
- perform a thorough evaluation before performing two ESI procedures;
- properly perform the ESI resulting in a spinal cord injury;
- provide proper pain management care and treatment; and
- address patient’s concerns during and after the ESI procedure.
Legal implications
According to consultants for the plaintiff, the pain management specialist did not meet the standard of care by failing to obtain a cervical MRI before administering the ESIs and opposing fluoroscopic X-rays during the procedures. Consultants for the defense echoed the concerns about lack of imaging.
Documentation for the second ESI presented an additional issue for the defense. The notes for both procedures appeared identical, which suggested a lack of attention to the procedure and documentation.
Disposition
This case was settled on behalf of the pain management specialist.
Risk management considerations
Consultants who reviewed this case argued that imaging could have been used to ensure accurate needle placement. Further, the lack of imaging caused the solution to be mistakenly placed directly in the spinal cord, which may have caused the injury.
The defendant recommended an MRI and physical therapy after the patient’s first injection, but did not follow up. He performed a second ESI even though the patient had not obtained the recommended MRI. When tests are ordered, a tracking protocol can help ensure results are received and communicated in a timely manner.
Consultants also stated that the physician should have been more attentive to the patient’s symptoms after the second ESI. The patient alleged during the second procedure he had a “jerking’ of his left arm and “stabbing” pain during the procedure. There is no mention in the documentation of the patient experiencing pain or involuntary “jerking” movements during the ESI.
Outpatient care and procedures in the office require increased responsibility for appropriate evaluation and monitoring. In addition, it is important to document any complication or unusual event that takes place during the procedure.
Postoperative monitoring and evaluation for an adequate period after an in-office procedure is suggested. Documentation in the medical record of the length of the patient’s recovery time and condition at the time of discharge is recommended.
Two days after the procedure, the patient notified the physician that his hand was numb after the appointment. Any symptoms reported later should be promptly followed up on.
This case was further complicated by templated documentation. The procedure notes for both rounds of ESIs were identical, and no mention of the patient’s complaints during the last ESI were documented. When templates for common procedures are used, the chart should be modified to reflect the actual care provided.
Olga Maystruk can be reached at olga-maystruk@tmlt.org.
Karen Werth can be reached at karen-werth@tmlt.org.