On October 25, 2017, the patient presented to the neurosurgery clinic at the Naval Medical Center Portsmouth for a second opinion on whether to undergo cervical spine surgery to address a long-standing history of cervical radiculopathy. Following an MRI, the patient was diagnosed with a C4-5 large disc herniation and severe foraminal stenosis at C7-T1.
On April 16, 2018, the patient presented to NMC Portsmouth to undergo an anterior cervical discectomy and fusion with globus stand-alone cages at C4-5 and C7-T1 to address paracentral cervical stenosis C4-5 and left-sided C8 radiculopathy due to foraminal stenosis C7-T1. The procedure lasted two hours and forty-three minutes. Notably, the surgeon did not dictate the Operative Report from this surgery until April 17, 2018.
Upon awakening after completion of the procedure, the patient could not move his lower extremities, had profound weakness in his hands, and was unable to void. An emergent MRI was ordered, which demonstrated “postsurgical changes . . . at C4-C5 with a small postoperative fluid collection causing mass effect on the anterior left ventral spinal cord with underlying cord signal change indicative of inflammation and/or edema” and “increased T2 signal changes in the spinal cord.” The surgeon recommended the patient undergo an exploration of the C4-C5 disc space, removal of the stand-alone cage, and a partial C5 corpectomy.
On April 17, 2018, the patient underwent these procedures, during which the surgeon removed the stand-alone spacer but did not replace it. Upon completion, patient was placed in a cervical collar and taken to the ICU where his neural examination was noted to be the same as prior to the surgery.
On April 18, 2018, MRI revealed “interval postsurgical changes at C4-C5 with interval partial decrease in compressive effect of the cervical spinal cord but overall increased T2 signal abnormality of the cord indicating continued myelomalacia” and postsurgical changes at C7-T1.
The following day, the patient was taken back to the operating room a third time to undergo another surgery for further stabilization due to the “latent instability of having disc removal as well as a partial corpectomy at C5.” Upon completion, the patient’s condition still had not improved.
Following this third surgery, the patient remained at NMC Portsmouth while the staff worked on getting him set up for spinal rehabilitation. Importantly, it was only at this point that the surgeon first documented what he purportedly did during the initial April 16, 2018 operation that caused the patient’s now permanent paralysis.
On May 3, 2018, the patient was transferred to the McGuire VA Medical Center in Richmond to begin rehabilitation for his quadriplegia. Upon admission, his spinal cord injury was graded as AIS C and he was noted to have worsened upper and lower extremity weakness and neurogenic bowel and bladder, which were “possibly due to reperfusion or manipulation.”
During his admission at McGuire VAMC, the patient made some progress – the grade of his injury improved to AIS D and he was noted to have improved ambulation with a platform walker – but his hospital course was complicated by C difficile colitis, multiple small pulmonary emboli, and a pressure ulcer. Ultimately, the patient was discharged from the McGuire VAMC and returned home on August 23, 2018—four months after the surgeries at NMC Portsmouth. Despite extensive rehabilitation, the patient continues to experience significant complications.
Rawls Law Group filed an administrative tort claim under the Federal Tort Claims Act on behalf of the injured patient, alleging (a) negligent performance of an anterior cervical discectomy with fusion; (b) negligent failure to adequately monitor and maintain appropriate blood pressures during surgery; (c) negligent failure to recognize and prevent a cord stroke; (d) negligent failure to prevent paralysis; and (e) negligent failure to replace the stand-alone spacer after removal on April 17, 2018. To the credit of the Navy’s Office of General Counsel, the claim was quickly resolved during the administrative phase without the need for litigation.