As a Texas medical malpractice attorney representing plaintiffs, I have witnessed the severe impact of complications following cervical spine surgeries, such as anterior cervical discectomy and fusion (ACDF).
It’s important for the nursing staff to keep a close eye on patients during the immediate post-operative period, because of potential complications including cervical hematoma and angioedema. These dangerous conditions are distinct, but share overlapping like respiratory distress, and require fast diagnosis and treatment to avoid dire consequences. This article explores the risks of these conditions, their differences, and potential medical malpractice in their management, using insights from a real case.
The Case: A Complex ACDF and Its Complications
Let’s discuss what happened to a man in his 50s who had an ACDF at the cervical spine levels of C3 to C7 at a Houston-area hospital. We’ll call him Sergio.
Sergio struggled with neck and arm pain, numbness, weakness in his hands, and difficulty walking due to spinal cord compression, disc herniation, and stenosis.
An ACDF surgery is done from the front of the neck instead of the back.
Performed under general anesthesia, Sergio’s surgery started with an incision on the side of the neck to access and decompress the C3-C7 disc spaces. The procedure was extensive, addressing significant herniation and cord compression at multiple levels. The surgeon inserted spacers filled with allograft were placed in the disc spaces, and secured a metal plate with screws to stabilize the spine.
After finishing the surgery, the surgeon noted that there were no complications and sent Sergio to the recovery room (post-anesthesia care unit/PACU) in stable condition.
Shortly after surgery, Sergio’s wife expressed her concern to the nursing staff that Sergio was having a tough time breathing. A nurse discounted her concern and told her it was just anesthetic effect, meaning that the general anesthesia drugs were wearing off. This initial response is a critical point of failure; dismissing patient or family concerns can delay life-saving care. For those interested in learning more about negligence during this vulnerable period, we have previously written about what you need to know about anesthesia medical malpractice, which covers the responsibilities of the healthcare team after surgery.
Later, though, the nurses saw that Sergio’s neck and tongue were swelling. It was then that they recognized that he was in respiratory distress, a critical warning sign.
Respiratory distress is a medical emergency where the patient has difficulty breathing, often due to not getting enough oxygen or impaired air exchange in the lungs. Symptoms include rapid or shallow breathing, shortness of breath, wheezing, stridor (a high-pitched sound), cyanosis (bluish skin), and anxiety or restlessness.
Swelling around the neck and tongue, combined with respiratory distress, pointed to airway obstruction from two potential causes: swelling in angioedema (rapid swelling of tissues, often involving the airway) or compression by a cervical hematoma (a collection of blood in the surgical site). In these circumstances, fast action, such as oxygen therapy, intubation, or addressing the underlying cause, is critical to prevent hypoxia, organ damage, or death.
The situation escalated quickly, requiring emergency intubation after six attempts by nursing staff. It took almost half an hour for a doctor to arrive after the Code blue was called, leaving nurses to manage the crisis initially.
The delay in recognizing Sergio’s deteriorating condition and securing the airway are the bases of a medical malpractice claim.
Cervical Hematoma: Risks and Malpractice Concerns
A cervical hematoma is a collection of blood that forms in the surgical site following procedures like ACDF.
It’s a known but serious complication, occurring in approximately 0.2% to 2.4% of ACDF cases, according to medical literature. The risk is higher in multilevel procedures, such as the C3-C7 fusion in Sergio’s case, because of the extensive dissection and manipulation of tissues during the surgical procedure. Blood loss during surgery (almost half a liter in Sergio’s case) can also increase the likelihood of post-operative bleeding.
Just because something is a known risk doesn’t mean when it occurs there wasn’t negligence at play. When reviewing a potential case, I think about how surgeons, physicians, and nurses should be extra cautious and on the lookout for those complications that they know might happen. In other words, while they can’t prevent a known risk from occurring, they’re still responsible for recognizing it and providing appropriate treatment when it presents itself.
A cervical hematoma can compress the airway, spinal cord, or surrounding structures, leading to symptoms like neck swelling, difficulty swallowing, or respiratory distress. In Sergio’s case, his swelling and respiratory distress prompted an emergency return to the operating room for exploration and evacuation of a suspected hematoma. Surgeons found and removed approximately 60 mL of old blood and clot but didn’t find active bleeding or significant hematoma.
Malpractice Risks in Managing Cervical Hematoma
Medical malpractice in managing a cervical hematoma often stems from delays in diagnosis or intervention. The standard of care requires vigilant post-operative monitoring by the nursing staff, especially in the first 24–48 hours when hematomas are most likely to form. When nurses recognize signs such as neck swelling, respiratory distress, or stridor (a high-pitched breathing sound), they should immediately notify the surgeon and request evaluation. This principle of diligent nursing care is fundamental to patient safety, as failures in even routine tasks can lead to severe harm. To understand another common area where nursing oversight is critical, you can read our article on how injuries occur when IVs go wrong.
When a surgeon assesses this type of situation, it will often involve a bedside examination of the patient, orders for diagnostic radiology, such as a CT scan, and a return to the operating room for surgical exploration.
In Sergio’s case, there was a significant delay in physician response, even after a Code Blue was called. This raises serious questions about whether the team followed the standard of care. Nurses attempted intubation six times before success, which may indicate inadequate training, staffing, or protocols for managing airway emergencies.
The failure to promptly recognize and address a cervical hematoma can lead to permanent injury, such as nerve damage or hypoxic brain injury, or even death.
Additionally, malpractice can occur if surgeons fail to control bleeding during the initial procedure or neglect to use appropriate hemostatic agents (medications that stop bleeding). While the surgeon’s second operative report reflects no active bleeding, the presence of 60 mL of blood suggests some degree of post-operative bleeding that went undetected in the recovery room.
Angioedema: A Different but Dangerous Complication
Angioedema, the other suspected cause of the Sergio’s respiratory distress, is a rapid swelling of the subcutaneous tissues, often affecting the face, tongue, or airway. It can be triggered by medications, allergic reactions, or, in rare cases, surgical trauma or anesthesia.
Unlike a cervical hematoma, angioedema is not a collection of blood but rather fluid leakage into tissues due to increased vascular permeability. In Sergio’s case, surgeon concluded that his respiratory distress was likely due to laryngeal swelling and edema from angioedema rather than a hematoma, based on finding no significant bleeding during the second surgery.
Angioedema is particularly dangerous because it can cause airway obstruction within minutes. Sergio’s rapid neck and tongue swelling, combined with the need for multiple intubation attempts, would be consistent with angioedema.
Malpractice Risks in Managing Angioedema
Managing angioedema requires rapid recognition and treatment to secure the airway and address the underlying cause.
When the healthcare team fails to make a proper diagnosis of angioedema as opposed to other conditions like cervical hematoma, it can lead to inappropriate treatment and medical malpractice.
For example, while a cervical hematoma may require a return to surgery to evacuate the excess blood, angioedema is typically managed with medications like corticosteroids, antihistamines, or epinephrine in allergic cases. In this case, the initial suspicion of a hematoma led to surgical exploration, which likely delayed targeted treatment for angioedema.
In addition, the significant delay in a physician response to the Code Blue is equally concerning for angioedema management. Airway emergencies demand immediate physician involvement, as nurses may lack the authority or expertise to administer certain medications or perform advanced airway interventions. Multiple failed intubation attempts further suggest potential deficiencies in staff training or equipment availability, which breach the standard of care.
When angioedema is the primary cause, the failure to administer appropriate medications promptly exacerbate swelling and can lead to dire consequences, including brain injury from a lack of oxygen, and even death.
Key Differences and Diagnostic Challenges
Distinguishing between cervical hematoma and angioedema is critical but challenging because of overlapping symptoms, such as neck swelling and respiratory distress.
A cervical hematoma typically involves localized swelling near the surgical site and may be accompanied by bruising or firmness, detectable on physical exam or imaging.
Angioedema, by contrast, often presents with diffuse swelling, particularly affecting the face, lips, or tongue, and may not be confined to the surgical area.
A CT scan can help identify a hematoma, while angioedema is often a clinical diagnosis supported by history and response to treatment.
In Sergio’s case, the surgical team’s exploration ruled out a significant hematoma, pointing to angioedema as the likely cause. However, the initial misdiagnosis or uncertainty highlights the importance of a systematic approach to post-operative complications. The failure to arrive at a correct and timely diagnosis is a recurring theme in medical malpractice. While the specifics differ, the devastating consequences are similar in other situations, such as when a doctor misdiagnoses breast cancer, leading to delayed treatment and poorer outcomes.
Preventing Harm and Seeking Justice
Both cervical hematoma and angioedema are life-threatening complications that require rapid, coordinated care. Hospitals and surgical teams must have robust protocols for post-operative monitoring, including frequent assessments of airway status, vital signs, and surgical site appearance.
Hospitals need to provide adequate nursing staffing to monitor for post-operative complications, and have appropriate coverage of surgeons and physicians on call to respond to emergencies. Additionally, all personnel should be trained in recognizing and managing airway complications.
For patients who suffer serious injuries caused by delays, misdiagnoses, or inadequate care, medical malpractice claims can provide a path to justice.
In Sergio’s case, claims focus on whether the nursing staff adequately monitored for bleeding or swelling post-operatively, delayed nursing notification of the surgeon, sluggish physician response to the Code Blue, and multiple failed intubation attempts.
Conclusion
Cervical hematoma and angioedema are serious complications of ACDF surgery that demand swift recognition and intervention. Both can lead to airway compromise, and delays or errors in management can result in catastrophic outcomes.
Sergio was a man in his 50s who developed a brain injury and later died based on poor nursing and surgical care.
If you or a loved one has been seriously injured because of post-surgical complications, contact an experienced Texas medical malpractice attorney to explore your legal options and protect your rights.
