Intubation is the placement of a flexible breathing tube into a patient’s airway so oxygen and anesthesia can be delivered during surgery. It can be done through the mouth or, as happened here, through the nose. Routine as it sounds, it depends entirely on careful positioning of the head and neck, and for patients whose necks do not move normally, that positioning has to be evaluated in advance.
Cerebral palsy is a group of permanent movement disorders that affect a person’s ability to move, control muscles, and maintain posture. In a patient with cerebral palsy, physicians must follow the standard airway protocols while making critical adjustments to accommodate neuromuscular spasticity, airway secretions, spinal deformities, and severe gastroesophageal reflux disease. Medical personnel must meticulously plan each phase to avoid triggering intense muscle spasms or risking aspiration.
When a patient’s individual anatomy is not accounted for before anesthesia, the consequences can be permanent. In this case, our client’s daughter suffered a cervical fracture, a spinal cord injury, severe cranio-cervical stenosis, and lasting neurological deficits. The Townsley Law Firm held the responsible parties accountable and recovered over $550,000 in a settlement on behalf of our client.
What Happened?
Our client’s daughter, who had cerebral palsy, underwent a dental procedure under general anesthesia. Sedation was required because of her acute stress reaction during invasive procedures.
Her cerebral palsy left her with a rigid neck and rigid facial and jaw muscles that she could barely move. That limitation was never evaluated before anesthesia staff attempted intubation. During the procedure her neck was manipulated in an unsafe manner and remained in a poor position for the duration of the surgery, fracturing the vertebrae at the occipitoatlantoaxial junction and causing a spinal cord contusion and severe cranio-cervical stenosis. She also never prescribed appropriate antibiotics before or after the dental work.
Three days later, her family brought her back to the emergency department, reporting that she had been crying and inconsolable since the surgery. Her jaw was drawing to one side, she was drooling, her head control had declined, and she could no longer use her left hand, which was her dominant hand. Those changes were reported again to the dental clinic in the weeks that followed.
Five weeks passed before anyone determined that she had a cervical fracture with an associated spinal cord injury and cranio-cervical stenosis.
The Series of Failures
This was not a single oversight. It was a series of failures that began before the child was ever put under anesthesia and continued for more than a month afterward.
No proper pre-operative anesthesia evaluation was performed. Because she had cerebral palsy, her neurologic examination, neck range of motion, and muscle tone all should have been assessed, and that assessment would have revealed rigid neck, lip, cheek, and tongue muscles she was only minimally able to move.
No diagnostic testing was ordered to evaluate her anesthesia risk, and no modifiable risk factors were identified or corrected before intubation. No alternative methods for safely securing her airway were prepared, and no practiced plans were in place in case a difficult airway was encountered. Nurse anesthetist students involved in her evaluation were not adequately supervised. Her baseline neurological status was never documented, leaving nothing to compare her post-operative condition against.
When her family returned days later reporting dramatic neurological changes, staff failed to appropriately assess and evaluate her. The information was there. It was reported, repeatedly, by the people who knew this child best, and it went unacted upon for five weeks.
The Consequences Faced due to Neglect
Severe dental abscesses, pockets of infection at the root of a tooth, normally prevented or treated with antibiotic, had developed in the absence of antibiotics, and those infections had to be treated before her spine could be repaired. An 8-pin halo ring and halo vest, an external brace, pinned to the skull and anchored to a vest, that holds the head and neck completely still while a fracture heals, were applied to stabilize her cervical spine and prevent further spinal cord injury. Three abscessed teeth were extracted days later.
She then underwent resection of the posterior arch of C1, followed by a posterior occipital-to-cervical instrumented fusion with titanium rods and wires, a structural iliac crest bone graft, and foramen magnum decompression. She required pharmacologic pain management until the day before discharge, and additional surgery for halo revision.
Before the dental procedure, she was a happy child who liked school. She could walk 300 feet with support at her hands or shoulders, climb three flights of stairs with contact guard assistance, propel her own wheelchair, and transfer on and off the toilet with only supervision. Afterward she was left with neurological regression, constant pain, emotional distress, fear and anxiety, painful orthotic devices, additional surgeries and therapy, lost time with her friends, and substantial additional medical expenses.
