Postoperative Paraplegia After Shoulder Surgery

Originally published by our sister publication Anesthesiology News

NEW YORK—In this issue, our series investigating anesthesia-related litigation reviews a case in which subpar supervision, a lack of standardized policies and procedures (or lack of knowledge of them), and poor communication led to postoperative paraplegia in a patient undergoing shoulder surgery. How could this happen?

At the 2023 annual PostGraduate Assembly in Anesthesiology, Patricia Fogarty Mack, MD, a professor of clinical anesthesiology at Weill Cornell Medical College, in New York City, and Michael Schoppmann, JD, the CEO of MLMIC Insurance Co., described the case, its fallout and how anesthesiologists can guard against similar situations.

Case and Circumstances

The patient, a 64-year-old woman who suffered a full-thickness rotator cuff tear and biceps tendon subluxation after a fall, underwent an orthopedic consult for the right elbow and shoulder pain resulting from her injury.

“Informed consent was documented, and the patient was scheduled for a left shoulder arthroscopy a month after her injury,” said Mack, who was not involved in the case.

Before the procedure, the patient, whose comorbidities included obesity and hypertension, received a regional block performed by a CRNA student supervised by a CRNA. Of note, the anesthesiologist was in the hospital but never saw the patient. During the procedure, the orthopedic surgeon requested that the patient’s blood pressure be lowered to improve visualization, so the student administered a double dose of hydralazine which raised the patient’s systolic reading above 90 mm Hg.

“Before leaving the hospital, the anesthesiologist texted the CRNA to see how things were going. The reply noted that the procedure concluded without complications,” Mack said.

While in the PACU, the patient continued to be hypotensive; the CRNA remained with the patient and administered medications to raise her blood pressure. After three hours, the patient’s blood pressure stabilized and she was transferred to a postoperative unit. The patient asked to use the restroom, and realized she couldn’t move her legs. “She said they felt like dead weight,” she said.

The CRNA and orthopedic surgeon were both called, but they had left the hospital. The CRNA informed the nurse that he could not give orders, and the surgeon contacted the emergency medicine physician to evaluate the patient until he could return to the hospital. The physician, concerned about a possible spinal injury, consulted a physician at a different facility for a possible transfer.

“There was no change in the patient’s motor deficit upon arrival and evaluation of the orthopedic surgeon,” Mack said.

The patient was transferred and eventually diagnosed with a spinal artery infarct; she remained paraplegic.

What Went Wrong?

“There was no chief of anesthesia, no appropriate mechanism for monitoring the care and they had no anesthesia policies for this procedure,” Schoppmann said.

The team also failed to follow a policy that was established by the facility, stating that when an anesthesiologist is unavailable the attending surgeon is responsible to supervise the CRNA. The use of hydralazine was called into question because it lasts longer than other medications that decrease blood pressure.

The opinion of the anesthesiology expert retained by the defense was that the case appeared to be medically sound, but that the lack of policies and procedures, and lack of supervision would make it hard to defend. Ultimately, the case settled for $550,000 in indemnity and $86,310 in expenses—amounts that would likely be as much as three times higher today—with the CRNA responsible for most of it. No payment was made on behalf of the supervising anesthesiologist.

Avoiding Such a Situation

“Often, we’ll look at a case like this and wonder whether it was an individual’s act of negligence or a system failure that caused the outcome. I think we’d all agree that this is replete with dozens of system failures,” Schoppmann said.

“Deviation from accepted standards—that’s a model for negligence throughout the country. Either there are no policies and procedures or a complete lack of communication in regard to policy and procedures. We see no education, no training, no documentation of the location of the injection—whether it was appropriate, and whether the dosage rendered was appropriate,” he said.

Mack pointed out that the orthopedic surgeon was not aware of the facility policy. “There were a lot of communication issues. There is also the question of who is responsible to train a student CRNA and what is the liability for the group and the institution,” she said.

Schoppmann urged anesthesiologists to protect themselves and their patients. “Be your own best risk manager. Wherever you’re working, be knowledgeable of the policies and procedures, the standards existing within. If they are inappropriate or inadequate, change them. If they will not change them, find a different place to work.”

He also stressed thorough documentation. “If someone’s going to read a chart eight years from now, are you going to be happy with the record? Did it speak well to your care, to the judgment and care that you rendered?”

Mack acknowledged that it is next to impossible to document absolutely everything, but that it’s important to document verbal consent of the patient somewhere in the writing, following a discussion of risks and benefits.

“And I try to include something personal about the patient, such as ‘patient is a fireman,’ or ‘sitting with wife.’ Something that shows you actually had a conversation with a patient, not just a checked box.”

By Monica J. Smith

Mack and Schoppmann reported no relevant financial disclosures.

Editor’s note: None of the cases explored in this series occurred at Weill Cornell Medical Center.