For the past several weeks, I’ve been investigating why the physicians and nurses at a major academic hospital in Houston’s Texas Medical Center missed the signs that a back-surgery patient was in danger of having a hemorrhagic stroke.
The patient had a multi-level lumbar and sacral laminectomy procedure. During the surgery, the surgeon’s grip of a drill slipped, lacerating the dura mater protective layer of the spinal cord and nerve roots. This is called an incidental durotomy and is a known risk of surgery. The surgeon recognized the dural tear and try to repair it.
Unfortunately for the patient, the surgeon, neurosurgery resident, and nursing staff apparently didn’t think much of the patient’s increased risk after he got out of the operating room.
One of the things that we always do at Painter Law Firm when investigating a case is dive into the medical literature. In this case, what we found was interesting. Medical studies and articles report that an incidental durotomy may cause cerebral hemorrhaging, including hemorrhaging in the cerebellum. This is exactly what happened to my client.
The medical literature also shows that surgeons should be on the lookout for any central neurological effects or unusual headaches. If these show up, the standard of care requires an order for emergency stat diagnostic radiology imaging studies, like an MRI or CT angiogram.
Central neurological effects
After any lumbar laminectomy or back surgery, let alone one where the dura mater was accidentally damaged, providers should be on the lookout for signs of central neurological effects. Some providers refer to these as focal neurological deficits.
To look for these critical signs, the standard of care requires surgeons to order the nursing staff to perform and document increased neuro checks.
Neuro checks are designed to establish a patient’s baseline and then are performed repeatedly and often produce the earliest indicators that something is wrong. Central neurological effects or focal neurological deficits are important after a back surgery because they can be linked directly to specific areas of the spinal cord or cranial nerves.
At a minimum, nursing checks would include orientation (to person, place, time, and location), reaction of pupils, speech, motor strength of extremities, and general movement and reflexes of extremities. Any abnormalities must be reported to the surgeon.
Examples of findings from central neurological effects or focal neurological deficits include:
• Changes in movement, such as modified muscle control, weakness, paralysis, or difference in muscle tone.
• Changes in sensation. This includes things like numbness or abnormal feelings like burning or pins and needles (paresthesia).
• Eyelid abnormalities. For example, the focal neurological deficit of ptosis (a droopy eyelid on one side) was the first big sign of a stroke in the case I recently handled for medical malpractice client.
• Altered speech. I represented clients in a number of stroke cases where there was slurred speech. In the case I discussed above, though, the patient had word-finding difficulties. Patients can also have deficits in reading and writing.
• Disturbances and vision. In an exam, providers look for things like double vision, altered visual fields, blurriness, and loss of vision.
It’s important for nurses to perform and document the neuro checks as ordered. For them to have any value, though, they also must pick up the phone and notify a physician when there’s an abnormality. That gives the surgeon or doctor an opportunity to assess the patient and order any additional testing or treatment that’s needed.
An unusual headache
The second big red flag for any laminectomy patient who had a dural tear is an unusual headache. If you think about it, there’s no real reason that a patient who had back surgery should have a headache. When there’s a dural tear at play, though, cerebrospinal fluid leaks out through the hole, causing a decrease in intracranial pressure. That can cause a spinal headache.
Surgeons often anticipate a spinal headache after a dural tear and order the head of the patient’s bed completely flat, which helps reduce the pain. According to a neurology expert that I’ve spoken with about my client’s case, if the incidental durotomy was properly repaired, then the body would eventually fully replenish the lost cerebrospinal fluid volume.
After that point, it’s appropriate for physicians and surgeons to start considering other explanations for a patient’s head pain. After all, a cerebral hemorrhage or stroke is a known complication of lumbar laminectomy surgeries, particularly when an accidental tear of the dura mater occurs.
To work up the possibility of a cerebral hemorrhage, our neurology expert explained that the first thing a surgeon should do is keep the patient’s bed completely flat and switch from narcotic pain medications to an oral medication like Tylenol. The reason for the medication change is powerful narcotic painkillers can modify a patient’s central blood pressure and intracranial pressure.
By making these changes and waiting a few hours, the surgeon can figure out if patient headache is related to a medication effect or not. If the headache persists, one of the next steps for a physician would be to order an emergency or stat MRI, CT angiogram, or other appropriate study to look for another explanation for the severe head pain.
In my client’s case, the head pain was so severe that it eclipsed the back pain he was experiencing from the surgery. His wife explained that she didn’t hear them even mention the back pain, in fact. He continued to have bad headache pain despite being on powerful narcotic pain medications, like Morphine and Dilaudid. The pain was so bad, in fact, that he refused to eat any meals.
Unfortunately, the nurses documented his ongoing unusual headache and focal neurological deficits, but never informed the physician. With the doctors kept at least partially in the dark, when they saw the patient, they presumed that he had a normal spinal headache and weren’t alarmed.
In the second day after his surgery, this poor man continued to get worse, dealing with head pain, refusing meals, and then becoming very sleepy (somnolent). Somnolence is another factor to look for in a neuro- exam and suggests something is wrong. The nurses didn’t inform a doctor about that either. Eventually, he developed word-finding difficulties and the nurses finally picked up the phone. By the time they called an emergency team, though, the patient had already experienced a hemorrhagic stroke.
After carefully looking at the medical records, our neurology expert concluded that the stroke could’ve been prevented. If the nurses and physicians had thought about his unusual headache and evolving neurological picture, it would’ve led to a much earlier order for a brain MRI, CT angiogram, or other study, which would’ve identified a slow brain bleed. That bleed would’ve been treated medically before cause any permanent injuries.
What you can do
As a patient or family member, keep these abnormal signs and symptoms in your mind when you’re hospitalized. If you notice things, be a squeaky wheel and tell the nurse. Make sure that the findings get communicated to a doctor promptly.
Some surgeons are legendary for not wanting to deal with post-operative complications, so be persistent and don’t take “no” for an answer.
We are here to help
If you or a loved one has been seriously injured because of poor anesthesia, surgical, medical, or hospital care, click here to send us a confidential email via our “Contact Us” form or call us at 281-580-8800.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. Also, in 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.