To Whom It May Concern
RE: A, John
At your request I have completed my review of the medical records kindly provided by your office in an organized binder and the imaging studies provided on four CDs concerning the care and treatment provided to Mr. A by the physicians and staff of the Kaiser Foundation Hospital, Santa Clara, California in regard to his traumatic cervical spine injury.
I am able to opine whether or not the standard of care was met and causation with regard to future disability. However, as is my practice in providing medical opinions with regard to the standard of care, deviations in the standard of care, or causation I do reserve the right to change or modify this medical opinion if new or undisclosed information becomes available for my review.
Briefly, as is well documented in the medical records, Mr. A at the time of his injury was a 66-year-old male who fell on the afternoon of March 19, 2012, striking the back of his head and had an immediate onset of neck pain. There was no loss of consciousness and Mr. A was transported to the Kaiser Foundation Hospital in Santa Clara, California emergency department. His C-spine was immobilized with a cervical collar and he was on a backboard. His initial physical examination revealed normal vital signs and grossly he was neurologically intact with a complaint of 10/10 neck pain. Mr. A was triaged appropriately and underwent evaluation by emergency room physician Dr. J who ordered a cervical spine series and CAT scan of the neck due to Mr. A’s body habitus. Radiologist Dr.B performed a standard AP/LAT cervical spine series that demonstrated vertebral alignment without evidence of obvious fracture and then performed a noncontrast CT of the neck, again according to his report demonstrating cervical spondylitic changes and no evidence of an acute fracture, noting the patient had “DISH” i.e. Degenerative Idiopathic Skeletal Hyperostosis. Those findings were relayed to the emergency room physician(s), now Dr. C who assume care from Dr. M and discharge the patient with the diagnosis of the cervical neck sprain noting cervical spondylitic changes and DISH as reported by radiologist. The patient was afforded pain control and advised to follow up with his family physician or if conditions changed.
Again from the documented medical records, on March 22, 2012, Mr. A presented to his family practice physician Dr. H at Kaiser Permanente, Campbell, California complaining of extreme neck pain and the inability to sleep. Treatment was conservative and Mr. A was sent home. It appears Mrs. A contacted the clinic the following morning stating that her husband has developed left arm weakness, tingling, with the inability to open and close his hand. With the question of a cerebrovascular event, due to Mr. A known comorbidities of obesity, hypertension, and atherosclerosis Dr. H on March 23, 2012 ordered a CAT scan of the head which was negative for ischemia and subsequently a MRI of the head which was performed on March 26, 2012, again revealing no evidence of an intra-cerebral event. An MRI of the neck should have been ordered.
Unfortunately, on March 28, 2012, Mr. A developed progressive neurological findings of a cervical spine injury with bilateral upper extremity weakness decreased grip strength and difficulty walking. He was evaluated at the Kaiser Foundation Hospital, Santa Clara California and was noted by the emerging physician to have bilateral upper extremity neurological deficits. A neurology consultation was obtained and performed by Dr. A who ordered an MRI of the C-spine and T-Spine. The findings demonstrate posterior epidural collection (hematoma) from C5 through C6 on the left extending inferiorly down to the level of T-1. An offset fracture of the C-7 vertebral body on T-1 was suspected. Mr. A was transferred to the Kaiser Foundation Hospital in San Jose, California and underwent emergent surgical decompression by spine surgeon Dr. M on March 29, 2012. Dr. M performed decompression of the epidural hematoma, decompression of the C-7 on T-1 fracture and decompressive laminectomy of C3-C7. Lateral mass in pedicle screws were placed bilaterally from C3 thru T2.
Again, from the medical record, it appears that Mr. A recovered postoperatively, strength in his right upper extremity but has residual weakness in his left upper extremity distally. It appears that he was a good candidate for rehabilitation therapy and physical therapy was begun. Pain control was adequate with oral narcotics and Mr. A was discharged home with follow-up appointments to spine surgery service and his family practitioner, and to a physical therapist on outpatient basis. I have no further records to review with regard to Mr. A’s current neurological status.
Commentary on the Standard Care, Deviations, and Causation
This case represents a deviation in the standard of care by the radiologist who interpreted the CAT scan on March 19, 2012 and a deviation in the standard of care by the family practitioner Dr. H for his failure to diagnose a posttraumatic cervical spine injury when presented with a patient who suffered a prior neck injury and complained of progressive neurological symptoms.
Based upon my education, training, trauma experience of 29 years, and supported by the medical
records my detailed criticisms of the substandard care are as follows:
The radiologist, Dr. B failed to identify the fracture and posterior fluid collection which is present on the CAT scan performed March 19, 2012. I am concerned when looking at the films, particularly images on sections L3P4H36 thru L5P4H36 and the subsequent soft tissue findings that a more detailed study should have been performed. This is not only based on the fact that you cannot clear the cervical spine based on a poor study and taking in account Mr. A’s body habitus, a MRI would have been more sensitive and specific in demonstrating the fracture. DISH is a consideration but a “garbage term” which is not specific particularly when evaluating the cervical spine and thoracic spine in the traumatized patient. I would recommend that a neuroradiologist specifically review that CAT scan performed on March 19, 2012.
With regard to the family physician, Dr. H, it is my opinion that the patient who presents with pain out of proportion to their physical findings, or has the onset of new neurological findings after a cervical spine injury needs an emergent evaluation by a neurologist and an imaging study specific to the injury. Mr. A’s neurological complaints, in the presence of known trauma, were suggestive of a cervical spine injury and not of a cerebral vascular accident. Although a prudent physician would rule out a transient ischemic attack or cerebral vascular incident, knowing Mr. A’s history of a traumatic fall with neck injury the only logical conclusion would be cervical spine injury or epidural hematoma. Again, Dr. H should have sent Mr. A to the emergency department for an imaging study and either a neurological or neurosurgical consult to reevaluate the injury sustained on March 19, 2012.
In summary, it is my opinion that the care provided by the radiologist and the family practice physician fell below the standard of care. The delay in diagnosis resulted in cord compression with neurological deficit; fortunately this was treated, although in a delayed fashion, with some recovery in Mr. A’s neurological function of his right upper extremity. I cannot comment on his current neurological deficit of the left upper extremity as I did not have those records for my review. If you have any questions after your review of this medical opinion, please do not hesitate to contact me.