A multi-level cervical fusion at the C3 through C7 levels is a significant spinal procedure involving the surgical stabilization of five consecutive segments of the cervical spine. The post-operative risks for this surgery include bleeding at the surgical site, neurological complications, and the risk of blood clots. Managing those risks requires close monitoring and access to the operating surgeon or a qualified covering surgeon who can respond rapidly if a complication develops.
A qualified covering surgeon is a licensed physician designated to stand in for the operating or primary surgeon. To be considered qualified, the physician must be board certified and must have hospital privileges, accredited training in a residency or fellowship program, an unrestricted license to practice medicine, and active competence.
One possible risk of a cervical fusion surgery is a cervical hematoma, which is a potentially life-threatening collection of blood in the neck tissues or spinal canal. This type of complication can cause breathing emergencies and irreversible neurological damage, requiring immediate medical evaluation.
In this case, our client developed a cervical hematoma after post-operative complications, in which the operating surgeon nor a qualified covering surgeon was available to perform life-saving treatment. Our client suffered quadriplegia from this neglect, and The Townsley Law Firm fought for his family to secure a settlement of over $4,250,000.
What Happened: Surgical Abandonment, a Preventable Emergency, and a Failure to Respond
The Surgery and the Surgeon Who Left
The Surgery and the Surgeon Who Left
The day after our client’s multi-level cervical fusion, his surgeon left the country. He did not arrange for another qualified spinal surgeon to assume coverage of his post-operative patients. Instead, a physician assistant was left in charge of his care.
A physician assistant is a licensed advanced practice clinician who can perform many important functions in a healthcare setting. However, a physician assistant cannot perform an emergency spinal surgery.
When our client’s surgeon boarded a plane and left the country, he did not fulfill his post-operative responsibilities to his patient. That abandonment was the first failure in a chain that ended with his patient’s death.
The Pulmonary Embolus, the tPA, and the Overdose
Our client developed a pulmonary embolus, a blood clot that travels through the venous system and lodges in the pulmonary vasculature, obstructing blood flow through the lungs. Treatment for pulmonary emboli is considered a medical emergency that requires prompt intervention.
The course of treatment chosen for our client included tissue plasminogen activator administration. tPA is a thrombolytic medication, meaning it is designed to dissolve blood clots. It is a powerful and potentially dangerous drug that requires precise dosing and careful administration. Too much of the drug causes systemic coagulopathy, meaning the blood loses its ability to clot, leading to uncontrolled bleeding at surgical sites, vascular structures, and anywhere else in the body where bleeding may occur.
Our client received an excessive dose. A tPA overdose in a patient who had just undergone cervical spine surgery, in which the surgical site involved the exposed structures of the spinal canal, was a foreseeable and catastrophic combination. The excessive anticoagulant effect of the overdose caused uncontrolled bleeding at the cervical surgical site, causing a hematoma to form.
The Hematoma, the Compression, and the Paralysis
A post-operative cervical hematoma is one of the most time-critical emergencies in spinal surgery. The cervical spine is surrounded by rigid, bony structures and the protective coverings of the spinal cord. When blood accumulates at a cervical surgical site, there is no space for it to expand without pressing directly on the spinal cord.
As the hematoma grew, it compressed the spinal cord at the levels where surgery had just been performed. The spinal cord, already in a vulnerable post-operative state, was being crushed by the accumulating blood.
The clinical signs of a developing post-operative cervical hematoma include new or worsening neck pain, difficulty breathing or swallowing, and the development of progressive weakness or loss of sensation in the arms and legs.
The time between the onset of cord compression and permanent neurological injury is narrow. Surgical evacuation of a cervical hematoma performed within hours of onset can often prevent or limit permanent neurological damage. Surgical evacuation performed after the cord has been compressed for too long cannot reverse the damage that has already occurred.
The physician assistant managing our client’s care did not have the authority, training, or surgical capability to perform a hematoma evacuation. The spinal surgeon who performed the original operation was out of the country, and no other spinal surgeon was called to intervene. Our client was not transferred to a facility with a neurosurgeon or spinal surgeon available to provide the emergency intervention his condition demanded.
He remained without surgical intervention while the hematoma compressed his spinal cord, ultimately resulting in quadriplegia.
Nearly Two Years of Paralysis and a Death at 66
Our client lived with spastic quadriplegia for nearly two years following the surgical catastrophe that took his function.
Complete paralysis of all four limbs requires around-the-clock care for every aspect of daily life. It brings with it a cascade of secondary medical complications including respiratory compromise, pressure ulcers, urinary tract infections, pneumonia, and the physical and psychological toll of losing control of one’s own body entirely.
He had come to a hospital for spinal surgery to improve his function and his quality of life. He died a quadriplegic because his surgeon left the country, and no one with the ability to help him was available when he needed them.
What Is a Post-Operative Cervical Hematoma and Why Is It a Surgical Emergency?
A post-operative cervical hematoma is a collection of blood that forms at the site of a cervical spine surgery in the hours or days following the procedure. The cervical spine is the portion of the spinal column in the neck, and surgeries performed on it, including cervical fusion procedures, involve working in close proximity to the spinal cord and the major blood vessels of the neck.
When post-operative bleeding is excessive, blood accumulates in the confined space around the cervical surgical site. Because the spinal canal is a rigid, enclosed space with no room for expansion, any significant collection of blood exerts direct pressure on the spinal cord. This pressure disrupts the normal blood flow to the spinal cord and mechanically compresses its neural structures.
The spinal cord does not tolerate prolonged compression well. Within hours of the onset of significant cord compression, neurological injury begins. Initially, the injury may be reflected as weakness or sensory changes that are potentially reversible if the compression is relieved quickly. As compression continues, the injury progresses from potentially reversible to permanent. The defining factor in the outcome of a post-operative cervical hematoma is the speed with which surgical decompression is performed.
This is not a subtle or controversial point in neurosurgery and spinal surgery. It is foundational. The standard of care requires that post-operative cervical patients be monitored specifically for the signs of hematoma formation, that those signs be recognized promptly, and that surgical evacuation be performed as an emergency procedure without delay when a hematoma is identified.
What Is tPA and What Are the Risks of Overdose in a Post-Surgical Patient?
Tissue plasminogen activator, known as tPA, is a thrombolytic agent, a class of medications that dissolve blood clots by activating the body’s natural clot-dissolving mechanisms. It is used in emergency situations including pulmonary embolism, stroke, and myocardial infarction to restore blood flow through vessels blocked by clots.
tPA is a powerful medication with a narrow therapeutic window. The appropriate dose is carefully calculated based on the patient’s body weight and clinical situation. When tPA is administered in excess, the thrombolytic effect is amplified beyond what is clinically intended, causing the blood’s clotting system to be overwhelmed. This condition leads to coagulopathy, a state in which the blood’s ability to form protective clots at bleeding sites is severely impaired.
In a patient who has recently undergone spinal surgery, the surgical site represents an area of active healing where small blood vessels are in the process of sealing and tissue is in the early stages of repair. When coagulopathy from tPA overdose is superimposed on this healing surgical wound, the normal hemostatic mechanisms that would limit post-operative bleeding are disrupted, and uncontrolled bleeding at the surgical site becomes a foreseeable and dangerous consequence.
The administration of tPA to a post-operative spinal surgery patient requires precise dosing, heightened vigilance for bleeding complications at the surgical site, and immediate surgical standby capability. In our client’s case, the surgeon who performed the spinal procedure and who would have understood that clinical context had left the country.
Physician Abandonment: When a Surgeon Leaves Before Post-Operative Care Is Complete
The standard of care in surgery does not end when the operating room doors close. A surgeon who performs a major procedure assumes responsibility for that patient’s post-operative management, which includes ensuring that appropriate coverage is in place for the post-operative period and that any surgeon who assumes that coverage is qualified to manage the procedure-specific complications that may arise.
For a patient who has just undergone a five-level cervical fusion, the covering provider must be a qualified spinal surgeon or must have immediate access to one. This requirement exists because the complications of cervical spine surgery, including post-operative hematoma, dural tear, and neurological deterioration, require surgical intervention that only a spinal surgeon can provide. A physician assistant, however skilled and competent in other respects, is not a qualified substitute for a spinal surgeon in the management of post-operative spinal emergencies.
Louisiana medical ethics standards and the standard of care applicable to surgeons prohibit a surgeon from abandoning a patient in the post-operative period without ensuring that adequate qualified coverage is in place. Leaving the country without arranging spinal surgery coverage for a patient who had major cervical spine surgery the day before is not an administrative shortcoming. It is physician abandonment, and it is actionable as a fundamental breach of the duty a surgeon owes to their patient.
The Duty to Transfer When Appropriate Care Cannot Be Provided
Even if the decision to leave the country and leave only a physician assistant in charge of post-operative spinal patients had not been made, the care team managing our client when his hematoma developed had an independent obligation that they also failed to meet.
When a patient’s condition requires a level of care that the current facility or the current care team cannot provide, the standard of care requires that the patient be transferred to a facility where that care is available. This obligation is well-established in medicine and is codified in federal law through the Emergency Medical Treatment and Labor Act.
When a patient who has undergone cervical spine surgery develops clinical signs consistent with a post-operative hematoma requiring surgical evacuation, and no spinal surgeon is available at the treating facility, the care team is obligated to recognize this, communicate it clearly, and arrange immediate transfer to a facility where a spinal surgeon can perform the emergency intervention.
Our client was not transferred. He remained at the facility where no qualified spinal surgeon was available while his spinal cord was being compressed by the expanding hematoma.
The failure to transfer was an independent breach of the standard of care, separate from the surgeon’s abandonment and the tPA overdose.
