Presentation

A 49-year-old woman came to see a physical medicine and rehabilitation physician (PMR Physician A) reporting a three-year history of neck pain. An MRI revealed the following:

• disc degeneration with a 4-mm herniation at C3-C4 with moderate central stenosis compressing the cord with severe left foraminal compression of the C4 nerve root;
• C5-C6 degenerative disc disease with moderate central and severe foraminal stenosis compressing the cord in the C6 nerve roots; and
• mild central disc bulge at C6-C7. 
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Physician action

PMR Physician B performed two cervical ESIs at C6-7 on June 10 and July 15 at the practice’s surgical center. At a follow-up appointment, the patient reported that the injections did not relieve her pain. PMR Physician A told the patient that her health insurance required her to have three cervical ESIs before she would be approved for surgical intervention. PMR Physician A scheduled the patient for a third cervical ESI on September 2.

PMR Physician A performed the ESI at C6-7 with loss-of-resistance and fluoroscopic technique. According to the medical records, the patient was under “light” sedation and flinched during the procedure. (“Light” sedation was later determined to be conscious sedation.) PMR Physician A reported that he then pulled back slightly and injected the steroid.

In the recovery room at the surgical center, the patient reported weakness in her left hand. PMR Physician A ordered dexamethasone 80 mg IV. EMS was called and the patient was taken to a local emergency department.

An MRI found “multiple foci of susceptibility in the cord, likely representing cord hemorrhage, worst at C6-7, associated cord edema that extends from cervicomedullary junction C7-T1.” 

A CT scan revealed “extensive hyper attenuation throughout the left greater than right subarachnoid spaces.” The patient was admitted and treated for a “cord hemorrhage post cervical ESI and acute subarachnoid hemorrhage.”

After her discharge from the hospital, the patient began treatment with a pain management physician for persistent axial neck pain, left arm and bilateral hand pain, numbness and tingling consistent with complex regional pain syndrome. The patient received a spinal cord stimulator implant with some resolution of her symptoms.

Allegations

A lawsuit was filed against PMR Physician A. The allegations were:

• failure to adequately document fluoroscopic guidance and confirmation of injection location;
• negligent use of sedation which caused a delayed reflex response; and
• negligence in puncturing the spinal canal due to poor technique.

The plaintiffs also alleged the procedure was unnecessary because the first two ESI did not relieve the patient’s pain.

Legal implications

While defense experts agreed that the “cervical epidural steroid injection procedure description was appropriate and met the standard of care,” several documentation issues made this case difficult to defend. PMR Physician A’s documentation was described as poor with the use of copy-and-paste templates. Copy-and-paste templates should be avoided, as they can create records that appear generic and incomplete. Documentation should clearly reflect the specific clinical circumstances of each encounter.

In addition, documentation for procedures such as ESI should include the clinical indication for the procedure, a description of the technique used, the number and placement of fluoroscopic images obtained, the patient’s response during and after the procedure, and any intraoperative events — such as patient movement or flinching — and how they were managed.

However, only one fluoroscopic image showing the final placement was included in the medical record. Had images been captured and retained at multiple steps of the procedure — including needle advancement, contrast injection, and steroid injection — they would have provided contemporaneous evidence of the physician’s technique.

There was also no documentation of the indication for the third ESI, which was consistent with the plaintiff’s claims that the procedure was unnecessary. Whenever a procedure is performed — particularly one in a series where prior attempts have not produced relief — document the rationale for proceeding.

Among defense experts, PMR Physician A’s decision to use “light” sedation was considered controversial due to the pros and cons of deep and light sedation with ESI. There was no documentation about the use of conscious sedation or why it was employed during this procedure. PMR Physician’s A defense would have been strengthened by documenting his rationale for deciding on the sedation used, the type and level of sedation employed, and how patient responsiveness was monitored.

Disposition

This case was settled on behalf of PMR Physician A.

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