MEDICOLEGAL CORNER. Failure to replace obstructed lumbar drain after thoracic-abdominal aortic aneurysm repair leads to paraplegia

BACKGROUND: To avoid spinal cord ischemia following endovascular/open thoracic-abdominal aortic aneurysm (T-AAA) repair, lumbar drains (LDs) are placed to reduce intraspinal pressure, and increase spinal perfusion pressure. Here, we present a medicolegal case in which a critical care (CC) physician knew that the LD was obstructed following a T-AAA repair, but did not replace it until the patient became paraplegic. The patient was left with permanent sphincter loss, and a severe paraparesis. METHODS: A geriatric patient with multiple medical/cardiovascular comorbidities first underwent an endovascular T-AAA (Crawford Type II T-AAA) repair several years ago. Due to continued expansion of the aneurysm, the patient now required an open T-AAA repair. RESULTS: Prior to the open T-AAA surgery, a prophylactic LD was placed. Postoperatively, the patient required a second emergency operation to repair a leaking intercostal artery anastomosis. The next morning, the CC physician clearly documented the drain was obstructed, but chose to follow the patient; 3.5 hours later, the patient became paraplegic. The LD was replaced after the patient was first sent to MRI to rule out a spinal cord hematoma, resulting in a total delay of more than 6.5 h from when the CC physician first became aware of the non-functioning LD. The patient later regained only partial function, remaining significantly paraparetic with total loss of bowel/bladder function. CONCLUSION: LD for endovascular/open T-AAA repairs reduce spinal fluid pressure, increase spinal cord perfusion pressures, and limits the frequency (i.e. 2.3–2.6%) of resultant spinal cord ischemia/paralysis. Here, despite the CC physician’s failure to replace an obstructed LD after an open T-AAA, repair, the jury rendered a defense verdict.