Name:
FOCUS25824video2
Description:
FOCUS25824video2
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Duration:
T00H06M12S
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https://cadmoreoriginalmedia.blob.core.windows.net/31c2cb95-4b59-49e3-ba13-a5573577ad77/2. 25-112.mp4?sv=2019-02-02&sr=c&sig=OzFhlhKZ0MOJSHtQ5F0Xgk8S5b6is5mYpkAtRCItDCY%3D&st=2026-05-13T19%3A54%3A37Z&se=2026-05-13T21%3A59%3A37Z&sp=r
Upload Date:
2025-12-11T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER 1: This is a case of an intraoperative iatrogenic
SPEAKER 1: injury causing an incomplete spinal cord injury. A man in his 6th decade presented with severe 9 out of 10 neck pain radiating into his bilateral shoulders. He additionally complained of loss of dexterity, numbness in his bilateral hands involving all five fingers, and a loss of balance. He was particularly affected on the left upper extremity with an inability to elevate his arm above his head.
SPEAKER 1: His prior medical history was limited with minimal medical care. However, he was a current everyday smoker. His physical exam was notable for weakness in bilateral elbow flexion and shoulder elevation, slightly worse on the left. Distal upper extremities were otherwise normal, including his hand intrinsics. While his reflexes were not hyperreactive, he was unable to perform a tandem gait, and his Romberg sign was positive. Examination of his shoulder was not consistent with a rotator cuff tear or tendinopathy. To assess root compression as a potential cause of his shoulder abduction weakness, electrodiagnostic studies were obtained of his left upper extremity. Needle electromyography demonstrated denervation in both the C5 and C6 myotomes. His preoperative MRI demonstrated severe narrowing at the C3 and C4 levels with anterolisthesis of C4 on C5 and moderate stenosis at C6–7. There was substantial myelomalacia from C2–3 to C3–4.
SPEAKER 1: Oblique images also demonstrated severe narrowing at the C3–4, C4–5, and C5–6 neural foramen. Standing films demonstrated dynamic C4–5 anterolisthesis that was worse than on his MRI, as well as having a positive cervical SVA. His diagnosis of cervical myelopathy with multilevel radiculopathy was consistent on physical exam, imaging, and electrodiagnostic studies.
SPEAKER 1: We felt it necessary to treat the severe spinal cord compression, his multi- level neuroforaminal stenosis, and his C4–5 listhesis, with consideration of whether his positive cervical SVA would improve with decompression. Our plan was to stage the procedure first with a C4–5 anterior cervical discectomy for treating the anterolisthesis and his worst neuroforaminal stenosis, followed by assessment of his alignment and then posterior decompression and instrumentation, depending on his postoperative align- ment, with planned C3 and C4 laminectomies and minimum C2–6 posterior instrumentation. Arguably, not treating the C6–7 narrowing and positive SVA was conditional based on his position and recovery. The anterior cervical discectomy was performed without complication. Standing imaging revealed normal alignment with C2 over the femoral heads. The second-stage procedure for decompression and instrumentation was performed the 2nd postoperative day from the anterior approach. In typical fashion, lateral mass trajectories were drilled with subsequent wide laminectomies at C3 and C4.
SPEAKER 1: Lateral mass screws were then placed with difficulty in achieving appropriate alignment of the screw heads on the patient’s left side. There was substantial back- and-forth discussion between the lead surgeon and assistant surgeon about placement of the lateral mass screws on the left side. After effort to fashion a rod to accommodate the screw placement, while placing the rod, the rod and the rod holder were accidentally impacted against the thecal sac.
SPEAKER 1: There was a sudden drop in repeat motor evoked potentials, and there was a transient drop in the left-sided somatosensory evoked potentials with subsequent recovery to baseline. Immediate imaging was obtained of the spinal cord, which revealed a left-sided spinal cord contusion. blood pressure augmentation for 1 day in the ICU, with greater weakness in the left upper extremity as well as bilateral grip strength weakness.
SPEAKER 1: Ultimately, he was discharged home 4 days after his second surgery. Three months after surgery, he described burning right hemibody pain and numbness with continued bilateral hand numbness and clumsiness. He continued to also have left lower extremity weakness. In subsequent follow-up, he had moved back in with his family and was turned down for disability. At 9 months after surgery, he disclosed suicidal ideation due to the severity of his pain.
SPEAKER 1: At 1 year after surgery, he reported only modest improvement in pain, as well as left-sided weakness, but also described difficulty sensing defecation. At 2 years, he reported minimal improvement in function with severe neuropathic right leg pain, difficulty with left hemibody coordination, and, at that time, had a recent fall which demonstrated stable hardware. While the ultimate error in this complication was the contusion of the left spinal cord, there were preceding factors that precipitated the error.
SPEAKER 1: First, there was a breakdown in intraoperative communication. The malaligned placement of the lateral mass screws made rod placement nearly impossible, which led to substantial back- and-forth discussion. The combination of the two frustrations may have also worsened attention to detail during placement of the rod. There was insufficient protection of the exposed cord, as the left side was contralateral to the individual placing the rod and the other surgeon was blocked from protecting the cord. Since rehabilitation was declined by insurance, the patient was discharged home. Potentially, this may have been altered with better engagement of risk management and other services, such as more extensive rehabilitation and pain management.
SPEAKER 1: In hindsight, we should have pursued better communication in the operating room when difficulties arose and, if they could not be improved, should have considered a time-out to allow individuals to recollect and refocus. A second surgeon should always place hands or other tools to protect the spinal cord when passing over the exposed spinal cord with a heavy instrument. Iatrogenic injury in training environments remains a challenge of education. Unfortunately, failure remains a powerful instructor.
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