Page 36 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

noted normal neuro checks until the third postoperative

day. At that time, there was a complaint of leg numbness.
An initial MRI was normal, and a neurology consult was

obtained. The patient did not improve. A repeat MRI was

performed and demonstrated positive swelling around the
cord at the epidural site. The patient developed cauda

equina syndrome. This condition failed to improve with
steroids. The outcome was devastating with the patient

becoming a paraplegic with a T-12 lesion post-surgery. A

lawsuit was filed.

Because of the failures on the part of the anesthesiologist

to communicate the risk of the epidural, the partner on call

was apparently unaware of the epidural catheter, and he
did not perform a neurological evaluation during the

postoperative visits. As noted earlier, the procedural
anesthesiologist also failed to write a procedural note on

the epidural placement which could have served as a

prompt for the follow-up care. Because of these failures,
this patient suffered a permanent and devastating

neurological injury that could have been foreseen with
proper evaluation and communication.

Recommendations that may have helped keep this type of

situation from developing include:

 Anesthesiologists/CRNA should provide information

about patients with anticipated problems to physicians
assuming care

Page | 36