In the summer of 2010, a 35-year-old man attended at his family doctor’s office complaining of back and leg pain. The family doctor, Dr. A, improperly diagnosed the man with Sciatica.
He returned to his doctor’s office in the fall of 2012 and again complained of back and leg pain. Dr. A ordered imaging studies of the spine, which showed disc protrusion in the thoracic, lumbar and sacral spine. No further investigations were completed.
In the winter of 2014, the man saw a specialist (physiatrist), Dr. B, on a referral from Dr. A, and complained of pain, weakness, reduced balance, falls, and numbness/tingling. That same month, he was referred to another specialist, Dr. C, who saw him on a number of occasions. The man’s symptoms continued to persist.
In the summer of 2014, he underwent an MRI of the spine at the defendant hospital. The MRI was reviewed by a radiologist, Dr. D, who incorrectly interpreted the imaging. Namely, the MRI demonstrated severe cervical spinal canal stenosis (narrowing) at the C3-C4 level with spinal cord compression. However, Dr. D attributed the changes at C3-4 to a disc protrusion, when in fact, the changes were due to ossification of the posterior longitudinal ligament (OPLL), resulting in severe canal narrowing with cord compression and ultimately, Cervical Spondylotic Myelopathy (CSM). CSM is a neck condition that arises when the spinal cord becomes compressed — or squeezed — due to the wear-and-tear changes that occur in the spine as we age.
Dr. D’s failure to correctly interpret the 2014 MRI was a clear breach of the standard of care. Urgent surgery to decompress the cervical spinal cord should have been strongly recommended to the man at this time.
Because CSM was not diagnosed by Dr. D after the 2014 MRI, the man developed severe bilateral leg weakness and spasticity that resulted in gait deterioration and significantly increased his risk of both falling and suffering a severe and permanent cervical spinal cord injury. Unfortunately, as discussed below, this is precisely what occurred in the fall of 2015.
He was reassessed by his family doctor, Dr. A, in January of 2015 on two separate occasions. At that time, Dr. A noted that he kept falling, could not hold his balance, and had hand weakness. As such, Dr. A referred him to a teaching hospital to be seen by a neurologist.
In the spring of 2015, he was seen by neurologists, Drs. E and G, who ordered several investigations. Subsequently, he was seen by Dr. H, a spinal surgeon, who correctly diagnosed him with CSM and recommended surgery which was scheduled to take place in several months.
This surgery should have been recommended in the summer of 2014 by Dr. JP, as discussed in paragraphs 4 and 5 above.
To make matters worse, his family doctor, Dr. A, failed to communicate a key part of the man’s medical history to Dr. H during the 2015 consultation: that he was repeatedly falling and was at a very high risk of a head or neck injury. Moreover, Dr. A received Dr. H’s consultation notes and knew that surgery would be several months in the future, yet made no effort to advise Dr. H that the man was at a high risk of an injury, and should therefore be managed as an emergency.
In the fall of 2015, 3 months after Dr. H saw the man, he fell down a flight of stairs and was rendered a quadriplegic.
There was an almost 1-year delay with progressive worsening of his spinal condition between the MRI in the summer of 2014 and Dr. H making the correct diagnosis of CSM in the summer of 2015. Had the severe cord compression at C3-4 that was clearly demonstrated in the summer of 2014 MRI been recognized by Dr. D, the man would have undergone urgent decompressive surgery at that time, preventing the significant worsening of his degenerative spinal condition.
Without this significant deterioration, he would have been much less likely to have fallen and suffered the severe spinal cord injury that occurred in the fall of 2015. It is likely that he would currently have normal or near normal spinal cord function, be fully independent, and employable. Instead, he has severe weakness in all four limbs, requires a wheelchair to mobilize, is unable to control his bowel, bladder and sexual function, and remains dependent on others for the vast majority of his daily living. His current disabilities are permanent.
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