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NEUROSURGERY
BARRX

Barretts esophagus is a condition that affects the lower end of the esophagus just before it connects to the stomach. In this condition the lining of the esophagus becomes different from the normal esophageal lining. This abnormality can change over time into a malignancy. Please refer to a recent article in the The New England Journal of Medicine that discusses Barretts Esophagus and it's treatment in detail. One of the treatment for BE is an ablation procedure by a device that cauterizes the abnormal tissues of the lower esophagus to eliminate the risk of cancer forming. When used correctly, this device called BARRX can eliminate the abnormal tissues of the lower esophagus and prevent any cancerous changes. If used incorrectly, severe problems can develop that can result in damage to the esophagus that led to strictures or narrowing of the esophagus. These problems may require further treatment such as esophageal dilatations or in the worst case, surgical resection of the esophagus. Cases in which the esophagus becomes damaged should be evaluated as to the indications for the procedure and the way in which the procedure was performed.

CRPS or RSD is a painful condition characterized by a failure of the nervous system to regulate input from the nerves of the body to the brain so that the patient feels hyperpathic symptoms such as severe aching, burning and chronic pain.
CRPS or RSD can be caused by medical negligence when there is a failure to diagnose or a by a failure to administer reasonable care.
Examples of such failures are: a large nerve in the arm or leg is stabbed by a needle during an injection or blood collection. A nerve that should be protected during an operation is not protected and becomes injured. A condition that can be diagnosed and treated correctly is misdiagnosed and the condition worsens turning into a CRPS type syndrome.
CRPS cases due to medical negligence are cases in which patients have a life changing experience. Frequently jobs are lost, relationships are changed forever and suffering is chronic and unrelenting.
At The Schlachter Law Firm we will evaluate your case and if meritorious, help to find solutions to compensate for the damages

TUMOR OF THE BRACHIAL PLEXUS RESULTING IN INJURY FROM RESECTION

In a case where a general surgeon operated on a mass above the clavicle, he discovered that the mass was not a lymph node but rather was a tumor of the brachial plexus.
The surgeon did not perform a frozen section biopsy. Had he done so, he would have discovered that the tumor was a schwannoma, a nerve sheath tumor. To remove a schwannoma, a surgeon must preserve those nerve fibers that are involved in the capsule of the tumor.
In this case, the surgeon removed the tumor and damaged or cut fibers of the brachial plexus because he failed to recognize the type of tumor that he was resecting.
The patient developed weakness and loss of muscle function in the shoulder and upper arm.
This case became a medical malpractice case alleging that the surgeon should have performed a frozen section biopsy and that he should have called surgeon more skilled in nerve preservation.

Should you have any questions concerning cases involving nerve sheath tumors or injuries of the brachial plexus, please inquire.

FAILURE TO DIAGNOSE CERVICAL CANCER

Most women are relying on the use of PAP smears and gynecological examinations to make sure that they are not developing cancer of the cervix. Most cancers of the cervix are detectable by changes seen on cells collected from PAP smears. These cells are sent to laboratories for analysis and the reports are sent back to the treating physicians.
If these specimens are misread by a technician or a machine, it is possible that the physican will get mistaken information concenring the degree of abnormality of the the PAP smear specimen. When this occurs, the patient is placed at risk because a growing cancer may remain undetected.
In terms of overall patient safety, it is not acceptable for abnormal PAP smears to be misread. Public safety in heathcare demands that competent persons review these slides and make the correct diagnosis.

If you have such a situation where a cervical cancer diagnosis has come to late, the case can be analyzed for an standard of care breaches.

ARTERIOVENOUS MALFORMATION HEMORRHAGE MUST BE RECOGNIZED IN A TIMELY FASHION TO ALLOW FOR NECESSARY TREATMENT

When a patient presents to an emergency department with the new onset of headache, lethargy or altered mental status without the development of a "focal" neurological deficit, it is imperative that intracranial hemorrhage be high in the differential diagnosis list. One can suffer a subarachnoid hemorrhage or an intracerebral hemorrhage without focal neurological deficit but with severe headache and altered mental status. What should be done to evaluate such a patient? A CT scan of the head. When should it be performed? quickly. Why? Because the causes of subarachnoid hemorrhages are treatable if diagnosed and treated before the lesion rebleeds. The same is applicable to arteriovenous malformations (AVMs)within the brain.
In my client's case, there was the new onset of a severe headache with lethargy. He was taken to a local hospital where he was evaluated in the ER. He was admitted to the floor for observation but no imaging studies were ordered. Some eight hours later, he decompensated neurologically and became comatose. One pupil dilated. He had an immediate CT scan that showed an intracerebral hemorrhage from an AVM. Surgery was performed to evacuate the blood clot and relieve the pressure. There was some permanent injury to the brain as a result of this delayed diagnosis. Time is of the essence when there is an intracranial hemorrhage and all medical care personnel have to look for such hemorrhages as a source of sudden severe headache in aptients who come to the ER.

CAUDA EQUINA SYNDROME CAUSED BY INTRAOPERATIVE COMPLICATIONS

In this case a 45 year old man underwent a lumbar laminectomy for back and leg pain. An intervertebral fusion spacer was placed and during the procedure, the dura was overretracted. This resulted in injury to the nerves of the cauda equina causing a cauda equina syndrome. This syndrome is characterized by urinary retention from bladder dysfunction, peroneal numbness or loss of sensation in the genitals and in the skin between the genitals and the anus. It is called "saddle" numbness. Also this man has weakness in his legs from L5 and S1 nerve root injury and an inability to control his bladder and bowels. Unfortunately this is a permanent condition and there is no known treatment.
Great care must be exercised by surgeons when retracting the dura to place intervertebral fusion grafts. There must be sufficient lateral exposure to allow for these large spacers to be placed safely.
In addition to the anterior fusion, most of these procedures involve placement of posterior stabilization with implanted pedicle screws.

On the importance of treating shunt obstructions in a timely fashion

Shunts are essentially plumbing devices that drain cerebrospinal fluid from either the ventricle of the brain or the subarachnooid space of the spine to another part of the body, usually the peritoneal cavity or the circulatory system. The purpose of this drainage is to prevent the buildup of pressure from a backup of the CSF that is not draining due to obstruction or reduced absorption of CSF. When a shunt, which is a mechanical device becomes broken or clogged in a patient who depends on that shunt, an emergency exists in that a limited amount of tiime is available to rectify the shunt failure before the pressure buildup results in neurologic damage.

Symptoms of shunt failure are headache, nausea, vomiting, confusion, double vision, and almost any other neurological sign. The surgeon works up the possible shunt failure with a number of exams that may include a CT scan of the head, a brain MRI, a shunt x-ray series, a contrast injection into the shunt done under fluoroscopy or a shunt tap to check flow.

When the failed shunt part or function is identified, surgery may need to be performed to establish CSF flow. It is important to establish flow before the pressure builds up to a level that causes herniation of the brain. All shunts have a limited lifespan, although many shunts last for many years. Usually the ventricles are enlarged when there is shunt failure although in some cases, the ventricles do not enlarge such as when there is slit ventricle syndrome.

Medical negligence claims are filed when patients who are shunt dependent are damaged when they not treated in a timely fashion after the onset of shunt flow obstruction. Shunt management can be simple or complex depending on a number of factors. A reasonable approach to diagnosis and treatment, including timing, is critical to the shunt dependent patient.

Pedicle screw misplacement

In a case where a lumbar fusion has been performed with instrumentation with pedicle screws, it is critical for the surgeon to carefully exam the patient after the surgery to make sure that there is not a new onset of neurological symptoms that were not present before the surgery. Increased radicular pain, new radicular pain, burning, hypersensitivity may be an indicator of nerve root irritation from a misplaced pedicle screw.

If there are new symptoms, a CT scan of the surgical site is important to evaluate screw placement and to rule out a misplaced screw. If there is a misplaced screw, the patient should be returned to surgery to reposition the screw.

We have had several cases where patients have gone on to have complex regional pain syndromes and a lifetime of chronic pain because of the failure of the surgeon to investigate misplaced pedicle screws in a timely fashion.

subarachnoid bleed and aneurysms

Listening to a patient is most important for a physician or health care provider. Whenever a patient says "I HAVE EXPERIENCED THE WORST HEADACHE OF MY LIFE!!!" everybody needs to consider the possibility of a subarachnoid or intracranial hemorrhage in that patient. Subarachnoid hemorrhage is usually the result of a ruptured cerebral aneurysm or of an AVM, an arteriovenous malformation. In such cases, immediate care by a neurosurgeon or by a team of specialists is critical. When a severe headache is accompanied by feelings of nausea, vomiting, decreased level of consciousness, focal neurological deficits (such as weakness on one side of the body or a dilated pupil of the eye), investigation into the cause of these symptoms is required.

In order to rule out the possibility of a cerebral bleed in these patients, a CT scan of the brain is required. At The Schlachter Law Firm, we have seen a number of cases where the failure to diagnose a subarachnoid hemoorhage has resulted in the failure to diagnose an aneurysm or an AVM of the brain. Most patients who are still alert who have suffered a subarachnoid hemorrhage are able to be treated through surgery or through newly developed endovascular techniques that prevent rebleeding of vascular lesions of the brain. There has been a great deal of progress in treating these vascular lesions and new devices are being evaluated. Identification of those with subarachnoid and intracerebral hemorrhges when they present to hospital is most important.

Dr Schlachter speaks at ACLM convention

There are cases where the physician makes a mistake during the operation that damages the patient. When is this due to negligence? When the error is unreasonable. Here is an example. During a spine operation such as an anterior cervical discectomy, the surgeon allows an instrument, most likely a knife, to penetrate the dura and injure the spinal cord. In my case, the patient has developed a Brown Sequard spinal cord injury. This injury is preventable with ordinary care by the surgeon. It is not a complication known to happen with reasonable care