In a lawsuit filed against The Villages Health System, a Village of Rio Grande resident claims he was left incontinent and paralyzed from the waist down after a botched procedure created a spinal hematoma that was subsequently misdiagnosed and ignored.
Attorneys representing James and Darlene Steigner filed the lawsuit against The Villages Health System, LLC, The Villages Tri-County Medical Center, Inc., and multiple other parties in the Fifth Judicial Circuit Court of Sumter County on August 27.
According to the complaint, while Mr. Steigner was a patient of The Villages Health System in 2022 and 2023, he was treated by Dr. Harsha Rajashekar for back pain.
Rajashekar, who is a pain management physician, diagnosed Steigner with lumbar spinal stenosis caused by ligamentum flavum hypertrophy, which is a thickening of the ligament that can narrow the spinal canal and compress nerves.
According to the complaint, Rajashekar recommended that Steigner undergo a “minimally invasive lumbar decompression (MILD procedure)” intended to alleviate pain caused by the spinal stenosis. The doctor allegedly told Steigner that the procedure was “less risky than an open back surgery” performed by back surgeons.
“The intended effect of a MILD procedure is to decompress spinal stenosis and reduce pressure through a small percutaneous incision,” reads the complaint.
Steigner agreed to undergo the procedure and scheduled the same at the Santa Fe Outpatient Center on Jan. 16, 2023.
Immediately following the procedure, Steigner began experiencing “severe, unrelenting and significant back pain” consistent with a spinal hematoma, which is a collection of blood within the spinal canal that can compress the spinal cord or nerves.
Spinal hematomas create symptoms similar to what Steigner was experiencing, including sudden severe back or neck pain, and neurological deficits. The condition can arise after trauma or surgery, and may be associated with spinal manipulation. Diagnosis is made with MRI and treatment typically involves emergency surgical drainage.
The complaint describes Steigner’s pain as “uncontrollable and inconsistent with the recovery expected” from a successful MILD procedure. It also alleges that the pain was “not relieved by pain medicine or any modality of pain treatment.”
At the time, a nurse told Steigner’s family that Rajashekar was considering sending him to the emergency room for the pain management. Instead, Steigner was given a “Percocet injection in the outpatient center and was sent home,” according to the complaint.
As he left the facility, Steigner had difficulty walking and entering his car due to his “intractable back pain.” When he arrived home, he required assistance to get into the house. His back pain continued to be so severe that his family called 911 to transport him to the emergency room.
According to the complaint, Steigner was transported to the Villages Hospital ER. His family contacted Rajashekar’s office to update the doctor on Steigner’s status and upon arriving at the ER, Steigner was “placed on a stretcher and left in a hallway.”
Steigner’s family claims it was “forced to approach medical staff” after there was a “delay” in tending to him. The ER doctor, Dr. Donal Spry, obtained information on Steigner’s MILD procedure and ordered pain medication, as well as a CT scan for diagnostic purposes.
The complaint alleges that Dr. Spry reported the CT results as normal and did not record any observations or differential diagnosis of a possible spinal hematoma, even though he was aware of the MILD procedure performed earlier in the day by Rajashekar and the unrelenting and intractable back pain suffered by Steigner following the procedure.
Additionally, Dr. Spry alleged did not refer Steigner to a neurosurgeon for diagnosis and treatment of his back pain. Instead, Dr. Spry turned over his medical care to a hospitalist nurse working at the Villages Hospital, according to the complaint.
On January 16, 2023, Steigner was admitted to the Villages Hospital. The complaint notes that the healthcare staff assigned to Steigner failed to order an MRI or recognize the spinal hematoma, misdiagnosing him and admitting him for overnight observation.
On the morning of January 17, 2023, another doctor assigned to Steigner’s case came into the hospital to assess him. At the time, the complaint notes that Steigner was still experiencing “uncontrollable back pain.” The doctor contacted Rajashekar and collectively, the group agreed to discharge Steigner from the hospital and send him to Rajashekar’s office for “sacral iliac (SI) injections.”
An SI joint injection delivers local anesthetic and a steroid into the SI joint to diagnose and treat pain originating from that joint, which connects the sacrum to the hip bones.
The complaint alleges that Steigner should not have been recommended for the injections because of his worsened condition and the “emergency caused by the ongoing epidural hematoma.”
“The SI injections were inappropriate for a patient suffering a spinal hematoma, which should have been recognized,” reads the complaint.
After Steigner was discharged from hospital on the morning of January 17, 2023, he was driven to Rajashekar’s office, where he required a wheelchair because he could not walk independently. While at the office, Steigner received two injections “which did not relieve the pain, but only intensified” it, according to the complaint.
At the time, Rajashekar allegedly told Steigner that it would take time for the SI injections to work before sending him.
When transported home, Steigner was once again unable to walk, even with assistance. The complaint alleges that his leges were “so weak” that he “physically collapsed and was stranded on the floor upon entering his home.” Emergency personnel were contacted and three fireman had to lift Steigner off the floor and position him in his bed.
Once again, Steigner’s family contacted Rajashekar’s office and advised of the worsening condition and Steigner’s inability to walk. The office staff allegedly “inappropriately responded” to the emergency and told the family that it would take “four hours for the SI injections to work.” They advised the family to provide Steigner with hydrocodone and ibuprofen every two hours and to call the office “the next morning” if he was still in pain.
Early on January 18, 2023, Steigner allegedly lost “all feeling in his legs.” The family again called Rajashekar’s office at 5:15 a.m. that morning with the updated information. Shortly after that call, Steigner allegedly became incontinent. At 9:25 a.m., Rajashekar’s office called back and advised the family to take Steigner to the emergency room at the UF Health Leesburg Hospital.
Steigner was transported by his family to the ER and, upon arrival, he was immediately diagnosed with a probable spinal hematoma. The ER physician ordered treating Steigner ordered an MRI that confirmed the diagnosis.
Physicians at the Leesburg hospital contacted neurosurgeons at UF Shands Hospital in Gainesville for an emergency neurosurgical consult. Those phycians concurred that Steigner’s medical condition was an emergency and he was “immediately transported” to UF Shands.
Emergency surgery was performed on Steigner and the spinal hematoma was evacuated. However, the “permanent injury, paralysis, incontinence and damage to Steigner was complete” at that point.
The complaint alleges that Steigner’s back pain ultimately caused him to become paralyzed and incontinent, saying the cause of “pain, weakness, incontinence, and immobility” was the spinal epidural hematoma “which began at the time of Rajashekar’s MILD procedure.”
In an operative report, the UF Shands doctor told Steigner’s family that the condition of his spine was similar to that of someone who had been in a “terrible car accident.”
After the emergency surgery, Steigner still continued to “suffer pain and severe disability, even following rehabilitation and physical therapy.” The complaint alleges he still suffers “irreversible and significant lower extremity weakness and disability.”
“James Steigner suffered a significant and permanent neurological injury as a direct and proximate result of the negligent treatment by the CFH and Villages Hospital staff, agents and employees, while a patient of the CHF / Villages Hospital,” reads a statement from the complaint.
The complaint lists 15 counts of negligence and one count of loss of consortium for Mrs. Steigner. The family is seeking more than $50,000 in damages, exclusive of attorney’s costs.