Sample Case Evaluation Reports - Neurosurgery Expert Witness
 

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Arteriogram Via the Oxillary (armpit) Artery Causes Injury With no Repair Done.

Certain salient aspects of this case are summarized below.

1) This Patient was 64 years old on March 3 when he underwent a balloon angioplasty of the proximal superficial femoral artery due to an ischemic left leg. This procedure was performed by Dr. Smith of Hospital #1. The details of this hospital admission were incomplete and no Informed Consent form was available for review. The signs and symptoms that he experienced due to this left leg arteriosclerosis, or "hardening of the arteries", were also unavailable.

2) The technique that Dr. Smith used was an axillary artery approach through the armpit, into the aorta and through the previous graft of the proximal superficial femoral artery. During this procedure, Dr. Smith noted a stenosis, or blockage, with difficulty passing this catheter, but an eventual successful balloon angioplasty with restoration of good arterial blood flow was achieved. During such a procedure, a narrowed artery is expanded using a catheter, which inflates a balloon-like device to widen the diameter of this blood vessel. Follow-up left leg ultrasound scanning on March 17 revealed improved blood flow, or at least a partially successful procedure.

3) Almost immediately in the postoperative period, he experienced left arm pain which was treated with pain medication. These records are also incompletely available and should be obtained. On March 6 he was evaluated by Dr. #2 of the Emergency Ward for continued left arm pain. Examination revealed motor and sensation abnormalities of several of his fingers. The case was discussed with Dr. #3 following a duplex-imaging scan revealed a partially clotted pseudoaneurysm of the left axillary artery. This is a known and usually preventable complication, but since it was causing symptoms, urgent surgery was indicated. For reasons that are unclear, no acute intervention, such as a decompression was felt to be indicated at that time, although the report of Dr. #4, the Radiologist, indicated a possible need for surgical repair.

4) This patient has been suffering from significant left arm weakness and median as well as ulnar nerve denervation symptoms since that time. He has been evaluated by several physicians, including Dr. #5 of the Hospital #2. In his note dated September 20, Dr. #5, a Neurosurgeon, recommended a probable need for decompressive surgery of the brachial plexus. Unfortunately, no further medical records were available following this date. 

In summary, patient underwent a balloon angioplasty procedure by Dr. Smith on March 3. It is unknown if this procedure was performed following proper informed consent, including the risks, benefits and alternative treatments to this procedure. It is also unclear if this procedure was performed using optimal precautions, and techniques, such as fluoroscopy, to avoid such complications as damage to the axillary artery and resultant nerve compression of adjacent nerve trunks. Following this postoperative complication, negligent Emergency Ward care appears to have been delivered by Drs. #2 and #3 as decompression surgery was delayed or omitted. Finally, he was evaluated on several occasions by Neurologists such as Dr. #6 and definitive decompressive surgery was again delayed or omitted.

In this specific case, Expert opinions in the areas of Vascular Surgery, Emergency Medicine, Neurology and Neurosurgery should be strongly considered to further bolster the merits of this case. However, it will also be helpful to obtain a more complete set of medical records.

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Lumbar spinal decompression and fusion becomes infected causing chronic pain. Operation not justified.

On 1/21, this patient underwent spinal decompression surgery removing bone, a thickened spinal fibrous ligament and disk material at the L3-4, L4-5 and L5-S1 lumbar spinal levels with removal of some disk material at those sites and a fusion bone graft procedure. Surgery was complicated by significant bleeding that the surgeon, Dr. #1, attributed to the patient taking aspirin before surgery.

Postopertively, the endotracheal tube used to give general anesthesia and oxygen during surgery was correctly left in place overnight because of the significant swelling of his head and neck from his face down (prone) position and the massive amount of fluid needed to maintain his stability during that bloody operation. The anesthesia care was good.

Postoperatively, he developed fever, headache and confusion. After consultations on 1/30, Dr. #1 performed a spinal tap at the L2-3 level and the spinal fluid was infected with the germ Staph aureus, the same germ that was the cause of his postoperative wound infection that was properly treated with the antibiotic, Vancomycin.

Because of the presence of the spinal fluid infection, (meningitis), the CT scan consistent with a blood collection (hematoma) which could be infected, and with additional consultation, Dr. #1 properly took him back to the operating room on 1/30. He found spinal fluid instead of blood at the operative site. He noted that "the dural (spinal cord and nerve root thin covering) opening was then (sutured) closed with interrupted #6-0 Prolene (very fine nylon) sutures, closure was done up to the point where the nerve root sleeve had some exposure of the nerve itself." At that point he noted, "There was virtually cessation of the spinal fluid egress from the subdural space and the dura then returned to its normal volume with the production of cerebrospinal fluid."

At the first operation he placed an electronic bone stimulator to help accelerate the healing of the bone graft for the fusion part of the operation. Since he found no overt pus (purulence) at this second operation on 1/30 it was a "judgment call" whether or not to remove it. Some would contend that it was negligent judgment considering the serous risks of a worsening of the infection in its presence, including meningitis and chronic osteomyelitis (bone infection).

Thereafter he received antibiotic therapy following his discharge from the Hospital #1, until 2/13. Beginning on 2/16, he became sick and was seen in the emergency room by Dr. #2 who performed a spinal tap confirming a recurrence of the Staph aureus meningitis.

He was transferred to the Hospital #2 where Drs. #3 and #4 operated on 3/4 and cleaned out the wound, removed the bone stimulator, loose and infected bone chips (confirmed by the pathologist, "acute and chronic osteomyelitis"), and inserted "antibiotic beads." They continued antibiotic therapy and re-operated on 3/6 to insert drains and close the wound.

At the 3/4 operation, Dr. #4 noted, "There was a clear suture noted in the dura at L5-S1 but the dura appeared waterproof and was tense (not leaking) so no further sutures were placed."

He was followed up by Drs. #3 and #4. The wound healed. As would be expected, the bone fusion did not solidify because of its increased risk of failure from the infection, the absence of the bone stimulator which had to be removed because of all the pus (purulence) that was found at that time, and his smoking.

The patient developed severe chronic low back pain and depression, which has been very difficult to control. That is related to the effects of the infection and the associated inflammation and scar tissue that occurs following an extensive operation which becomes infected.

The care at Hospital #2 thereafter was good.

With any decompressive spinal operation a dural tear can occur, and in the presence of extensive bleeding, there is an increased risk that vision of the Surgeon is more likely to be obscured. As noted in his five-page operative report dictated two days after surgery and before the subsequent complications surfaced, Dr. #1 took precautions to prevent such injury. He stated, "Cottonoid Paddies (postage stamp felt-like pads) were placed toward the advancing margin of the lamina (bone) to attempt to separate the dura from the lamina to prevent capture (grabbing) by the rongeurs (bone biting and cutting pliers-like device), and this was successful throughout the procedure to prevent dural tearing."

In my opinion, if he snagged and tore it at that operation, or if the bone graft cut into it over time, that is not from negligence. In fact, at the second operation on 1/30 he said, "At the L5 laminectomy (spinal bone removal for decompression) site there appeared to be some thinning out of the dura at one point where a portion of the bone graft was opposed to the dura, a shift of the posterolaterally placed bone graft element which had impinged on the dura but had not completely penetrated into the subdural space." He previously described a 1.5 cm (3/5 inch) rent (hole, tear) in the dura and said, "There was some fraying of the dura toward the more cephalad (head direction) portion of this rent."

I have a few concerns. The first is whether or not the patient was warned not to take any aspirin or aspirin-containing medication for one week before the operation. The failure to warn is negligent. The bleeding increased the risk of dural tear and infection to some degree.

The next concern is whether or not he should have undergone the operation at all. He hurt his back less than one month before, had some physical therapy and a brief hospital stay plus traction (1/2 - 1/6). The MRI scan showed significant disease at those three levels, which produced spinal stenosis (hourglass-like deformity) which could put pressure on the spinal nerve roots causing his symptoms. On 1/20 the radiologist, Dr. #5, compared the plain lumbar x-rays he took to the prior MRI and x-rays from Dr. #1's office and did "confirm apparent bilateral spondylosis of LS without spondylolisthesis (one bone shifting out of position over the next one). He does not mention any spinal stenosis, narrowing of the hollow space within which all the spinal nerves pass. You should authorize us to have those x-rays and MRI evaluated by a Neurosurgery Expert and/or Radiology Expert.

Furthermore, I was very surprised to find in Dr. #1's admitting physical examination, "Straight leg raising test negative at 90 degrees." With the spinal nerve root(s) being irritatively compressed to cause such pain, by having the patient lie down and lift the foot (and leg) upward, it stretches the sciatic nerve and ligaments and would cause severe pain at even 20 to 30 degrees. There was no pain at 90 degrees! Based on that, I have even more serious concerns as to what the MRI showed and why the patient was not offered more conservative therapy (time to heal) since there was no weakness, loss of reflexes, bladder or bowel symptoms to rush into an operation. Ninety percent of patients given adequate conservative therapy do well. As I noted, I believe he was denied that opportunity. Without the operation, there would be no infection, dural leak and meningitis. There would also be no severe chronic pain and depression.

My next concern relates to the development of the infection and to its source. As noted, the back was correctly cleansed and sterilely draped at the beginning of surgery. According to the discharge summary dictated four months later, he also received an infection prophylactic (preventative) dose of the antibiotic, Vancomycin, immediately before that operation. Did he? I have not seen the Doctor orders sheet, the medication index, the anesthesia record or the Operating Room Nurses notes which should be obtained for the first two days of his hospitalization (1/21 through 1/23). Since they were performing a bone graft procedure and inserting the "foreign body" electrical bone stimulator, if he did not get the prophylactic antibiotic, as noted, which usually is given for one or two days after surgery too, that would be negligence and increase his risk for infection. Please supply those missing records so I can prepare an addendum report on that issue.

I have a concern involving his smoking two packs per day, and as Dr. #1 noted in the Admitting History, "Successful spinal fusion is enhanced by cessation of cigarette smoking. This has been encouraged." Was the patient really advised and how was he "encouraged?" Was he sent to any program to help him stop before this elective operation?

My final concern is whether or not the hospital's Infection Control Committee investigated this Staph aureus infection to try to determine its source. Those records should be obtained. Did Dr. #1 have an excessive infection rate? Was his nose and throat ever cultured to see whether or not he was a carrier of Staph aureus? If they failed to do so, the hospital would be negligent, especially if his other patients also contracted Staph aureus infections.

Based on the above, there may be negligent care as the cause of the patient's current chronic pain and depression for all the reasons stated. After I review the requested documents I would suggest that good copies of the preoperative lumbar x-rays and MRI be obtained and that we have this case first reviewed directly by a Neurosurgeon, then an Infectious Disease Expert and finally by an Orthopedic Surgeon with spinal surgery expertise.

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The patient had an intra-cerebral artery aneurysm operated upon successfully, but 2 years later has identical recurrent symptoms and delay in emergency surgery, causing massive brain swelling and death.

A cerebral aneurysm is a weakness in the wall of a blood vessel, like a bleb on an inner tube of a tire. When it is small, it may not cause any symptoms, but with each heartbeat, the blood pressure can enlarge it over time. As the aneurysm starts to stretch, it can stretch more easily as it expands. This is like blowing up a balloon -- difficult at the beginning, but easier as it begins to inflate.

The patient had a strong family history of cerebral aneurysms, she had a severe headache, was admitted to the hospital neurologically intact, and was diagnosed as having a cerebral aneurysm based upon the arteriogram (artery x-ray dye study). This was performed on January 17, by the radiologist who stated, "there is a posterior communicating artery aneurysm which appears to point predominantly posteriorly and inferiorly. There appears to be a fetal origin of the posterior cerebral. The aneurysm appears to be relatively broad-based and measures in the range of 6-7 millimeters. There is no surrounding vascular spasm."

On the basis of that arteriogram and her symptoms, she underwent surgery by Dr. #1 at Hospital #1 on January 18. He separated (dissected) the layers of flesh using the microscope, and said, ". . . and then sharp dissection was carried out to free the aneurysm from what was a very large and dominant posterior communicating artery. With this having been accomplished, a Sugita straight aneurysm clip was able to be gently eased into place over the base of the aneurysm and released, allowing total ablation (elimination) of the aneurysm but yet good preservation of flow of the carotid artery, a very thin posterior choroidal artery that was visible and, as mentioned, the large posterior communicating artery. The clip was felt to be in good position, was totally obliterating the aneurysmal neck. The aneurysm was totally slack."

Thus, he placed the V-like shaped metal clip across the broad base of the aneurysm and was able to eliminate all communication between it and the posterior communicating artery. Furthermore, the operative report was dictated the same day of surgery, which would assure some accuracy.

Postoperatively, the patient did well and had minimal neurologic difficulties that improved as time passed, according to the office records of Dr. #1.

She was also under the care of Dr. #2. She was seen for a sinus infection. He noted her history of the aneurysm surgery performed the year before, as well as the strong family history involving aneurysms of the brother, mother, cousin, and grandfather. During this visit, he noted that the right maxillary sinus was "tender," and therefore the appropriate diagnosis of sinusitis was made, and she was prescribed an antibiotic and antihistamine medicine.

A year later she was seen with similar problems. She was complaining of sinus pressure, and he diagnosed sinusitis and noted that she had been taking two antibiotics. He gave her a potent steroid medication Depo-Medrol, and a tranquilizer, Tranxene (which his office records misspell as Transene). This care was appropriate.

The final records of those of November 4, and say that the chief complaint was migraine, but she went to the emergency room. There was no medical examination in his office, and I am not sure if he actually saw the patient on that date. When patients have migraine headaches, they have a long history of migraines, usually beginning in childhood. They don't have a migraine history coming out of the blue. She had already been seen by the Emergency Room Physician the night before, and again on November 4, when she was admitted to the hospital.

In the Emergency Room, she was seen by Dr. #3. This was on November 3, at 19:13 (7:13 PM). The record claims that she was seen by Dr. #2 in his office on Tuesday, for a sinus infection, and he called in the antibiotic, doxycycline, but according to his records, there was no visit in November or October.

If a patient has a long history of a sinus problem, and if the symptoms are consistent with that condition, it is a judgement call as to whether or not the physician will see the patient. But, if the symptoms are totally different or much worse than before, then it would be a departure from the standards of care not to see and examine the patient.

According to the statement of facts, the patient had ten days of a headache and was being treated by Dr. #2, the Primary Care Physician, for sinusitis without relief. She called a Neurosurgeon, Dr. #1, but he was not on call and she was advised to go to the hospital Emergency Room.

The Emergency Room record shows that she had a right-sided headache, and the two-page typed emergency room visit noted that the patient "this week started having some right-sided headache. Dr. #2 called her in some doxycycline (antibiotic) and she has been taking some Sudafed (decongestant). The pain got worse today with marked photophobia (severe light sensitivity), nausea. Nose actually feels clear. She has marked photophobia, no numbness and tingling anywhere. No loss of strength anywhere. No visual changes except for photophobia." He noted the history of the brain aneurysm, and sent her for a CAT scan of the head that "was read as negative by the Radiologist." His diagnosis was "right-side cephalgia," which means headache. She was given 100 milligrams of Demerol, a potent narcotic, and 50 milligrams of Phenergan, which is a tranquilizer that relieves nausea and increases the potency of the narcotic. The records says, "go home and let the medicine put her to sleep and sleep this off. When she wakes in the morning, if she still has a headache, she is to contact Dr. #2."

There is an attached record by Nurse #1, who appears to be a registered Nurse. This says, "I've got pain in my head," complaining of right-sided throbbing pain. Has been treated for sinus infection since last Wednesday. Has history of two aneurysms - two years ago, and relates similar symptoms. Also complains of nausea and vomiting (N/V), positive slight photophobic."

Based upon this note, where the patient related similar symptoms to her previous aneurysm two years before, with no relief after one week of therapy for sinusitis, and with the emergency room physician noting her nose was clear and does not describe an examination of her face with regard to tenderness over the sinuses, or even a thorough examination of her ears and throat, in my opinion, he should have had the Neurosurgeon contacted.

Since the patient complained of symptoms similar to what she had two years before, did not respond to one week of therapy for sinusitis, and he had nothing in the records to show that she had sinusitis, to diagnose"right-sided cephalgia," give her a narcotic injection and a tranquilizer, and send her home "to sleep it off," in my opinion, would be a departure from the accepted standards of care.

Under these circumstances, in my opinion, the patient should have been seen by a Neurosurgeon. If her previous neurosurgeon was not available, I am sure that there is more than one Neurosurgeon available in that large city.

Most likely, an MRI examination would have been performed if she had been seen by a Neurosurgeon, and possibly an arteriogram. In my opinion, those probably would have shown the aneurysm, based upon what I will describe below, because of its size. Then, the patient could have been operated upon for a symptomatic aneurysm before it ruptured with the potential for a better outcome.

After going home as instructed, she was again seen by this emergency room physician, Dr. #3. The patient had passed out on the way to the hospital but was neurologically intact on arrival. A repeat CAT scan this time showed subarachnoid hemorrhage (hemorrhage surrounding the brain). Dr. #3 discussed the case with Dr. #1 and the neurosurgeon resident, and she was admitted into the hospital.

On November 5, an arteriogram study was performed and compared to the one of 18 months earlier. The aneurysm was in the same position, but "it is somewhat larger today in AP (front to rear) diameter, extending posterior to the dorsum sella as seen on the lateral projection, with the posterior margin of the aneurysm extending only to the anterior margin of the dorsum sella on the previous exam. This corresponds to an AP (anterior-posterior) diameter of about 1 centimeter maximum. A definite neck (the narrow part of an aneurysm like the stalk of a mushroom that is often but not always seen) is difficult to identify in any plane, including the spin study." Thus, this was a broad-based aneurysm in the same general location as the one seen earlier, but larger. And is says, "slightly lobulated intra-cranial aneurysm which appears to arise at the origin of the posterior communicating, and immediately adjacent to an aneurysm clip which is in place."

Based on that finding, and the fact that there was no spasm in the arterial blood vessels in that area, surgery was indicated. If there were spasm, surgery would be contraindicated, because operating can make spasm worse.

She was taken to the operating room by Dr. #1 with the assistance of Drs. #4 and #5. Again, using the microscope, he dissected the layers of flesh, but it was more difficult because of the previous aneurysm, therefore there was more scar tissue. He said, "as further dissection was carried out to establish a neck; however, the aneurysm began brisk arterial bleeding, and at this point a straight clip was placed at the origin of the aneurysm from the internal carotid artery. This unfortunately did not allow complete aneurysm obliteration as the point of bleeding from the aneurysm was at its very origin from the carotid wall and an additional clip was placed which for a short time allowed total cessation of bleeding. . ."

The clip was impinging a nerve, and therefore they tried to move it. Bleeding increased, and with digital pressure he controlled the bleeding while Dr. #4 operated upon the neck to locate the internal carotid artery (the main artery to that side of the brain) and put a clamp across that site.

That controlled bleeding, and therefore a permanent clamp was placed at that location. That controlled the bleeding, and the skull and scalp were sutured closed. The patient had evidence of paralysis of her left upper extremity, but otherwise was reasonably alert and intact. Unfortunately, she developed massive swelling of the part of the brain supplied by the middle cerebral and anterior cerebral arteries, which would be supplied by blood from the internal carotid artery that was clamped closed. This "stroke" progressed further with massive swelling of the brain, not controlled by appropriate medications. The patient had another CAT scan that showed that but no subsequent hemorrhage, and despite the conservative therapy, the patient died. No emergency resuscitation was performed pursuant to the request of the patient prior to surgery.

The autopsy confirmed the damage to the brain from the impairment of blood flow and the location of the clips. They also found another small aneurysm involving the right superior cerebellar and basilar arteries, not involved with the surgery in question.

Based upon all the above, it appeared the patient had a large, broad-based aneurysm, as opposed to a narrow neck type aneurysm, involving a large posterior communicating artery that had a metal clip applied. That was successful and described as such the same day of surgery in the dictated operative report. The patient did well for two years and developed further symptoms that were consistent with her previous aneurysm symptoms.

Despite that, having come to the Emergency Room, even with a negative CAT scan, no Neurosurgeon was contacted. The patient was given medication for pain and nausea, was sent home, and returned with a recurrent hemorrhage. The aneurysm had leaked. That makes the operation more difficult.

The repeat operation involved hemorrhage at the leaking aneurysm site, and by necessity the internal carotid artery had to be ligated (clipped) which caused a severe stroke which led to further swelling of the brain, and despite conservative therapy, the death of the patient.

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Although, in my opinion, the Emergency Room Physician departed from the accepted standards of care, there may be some difficulty in showing causation. First of all, with the previous operation, any operation at that site is certainly more difficult, particularly with an aneurysm that was a broad-based one. I was concerned that the neurosurgeon may have missed clipping the aneurysm, but the operative report is quite clear, as I quoted above, with regard to the first procedure performed 18 months earlier.

It appears she had a further weakness of the artery next to the clip, and that developed into a further progressive broad-based aneurysm, larger than the one two years before. Even if it had not bled, there would be significant difficulty in performing surgery under the circumstances, and that would be the major defense -- the "so what" defense. With any operation at this site, even using the microscope, the operation is quite tedious. At surgery, when the area was located, it did not initially hemorrhage until further manipulation occurred. The Defense would argue that that would have happened even if the patient would have been operated upon a few days earlier, or perhaps even weeks earlier in time.

I believe it may be possible to obtain supportive testimony by an Emergency Room Physician, but it may be much more difficult to obtain testimony by a Neurosurgeon and/or Neurologist that it made any significant difference to the final outcome.

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