See What You'll Receive

Dr. Sarah Chen, M.D., FACS, is a board-certified orthopedic surgeon with 18 years of clinical experience specializing in spinal surgery and biomechanics. Dr. Chen holds a Doctor of Medicine from Johns Hopkins University School of Medicine and completed her residency at Massachusetts General Hospital. She is a Fellow of the American College of Surgeons and has published 47 peer-reviewed articles on spinal biomechanics and surgical outcomes. Dr. Chen has been retained as an expert witness in over 60 medical malpractice cases and has testified in both federal and state courts. Her opinions have survived Daubert challenges in 14 separate proceedings across 8 jurisdictions. In forming the opinions set forth in this report, Dr. Chen reviewed the following materials: • Complete medical records from Regional Medical Center (January 2024 – August 2024) • Operative reports dated March 15, 2024 and June 22, 2024 • Pre-operative and post-operative imaging studies (MRI, CT, X-ray) • Deposition transcripts of Dr. James Morrison and Dr. Patricia Williams • Medical literature on lumbar fusion techniques and complication rates • Relevant clinical practice guidelines from the North American Spine Society Dr. Chen is being compensated at a rate of $650 per hour for review and report preparation, and $750 per hour for testimony. Her compensation is not contingent upon the outcome of this litigation.

The methodology applied in this analysis follows the differential diagnosis framework, which is a systematic approach widely accepted in the medical community and consistently upheld under the Daubert standard. See Westberry v. Gislaved Gummi AB, 178 F.3d 257 (4th Cir. 1999) (endorsing differential diagnosis as a reliable methodology for medical causation). The analysis proceeds in three steps: Step 1 — Comprehensive Review: Identification of all potential causes of the patient's condition through review of medical records, imaging studies, and clinical literature. Step 2 — Systematic Elimination: Ruling in or ruling out each potential cause based on clinical presentation, temporal relationship, objective findings, and peer-reviewed literature on risk factors and complication rates. Step 3 — Causation Determination: Arriving at the most probable cause based on the remaining differential, applying the "more likely than not" standard (>50% probability) consistent with medical causation requirements. This methodology is grounded in the general principles of evidence-based medicine and has been applied in accordance with the clinical practice guidelines published by the North American Spine Society (NASS) and the American Academy of Orthopaedic Surgeons (AAOS).

Mr. Robert Alvarez, a 52-year-old male, presented to Dr. James Morrison on January 12, 2024, with complaints of progressive lower back pain radiating to the left lower extremity, numbness in the L5 dermatome, and difficulty ambulating. MRI of the lumbar spine dated January 15, 2024, demonstrated a left paracentral disc herniation at L4-L5 with moderate foraminal stenosis and compression of the traversing L5 nerve root. Conservative treatment was attempted over a 6-week period, including physical therapy, epidural steroid injections, and oral analgesics. When symptoms persisted and progressive motor weakness was documented (left extensor hallucis longus strength graded at 3/5), surgical intervention was recommended. On March 15, 2024, Dr. Morrison performed a left L4-L5 microdiscectomy and foraminotomy. The operative report documents an unremarkable procedure with estimated blood loss of 75 mL. However, post-operative imaging obtained on March 18, 2024, revealed residual foraminal stenosis with ongoing nerve root compression that was not adequately addressed during the initial surgery. Mr. Alvarez continued to experience radicular symptoms post-operatively. A revision surgery was performed on June 22, 2024, by Dr. Patricia Williams, which included an L4-L5 transforaminal lumbar interbody fusion (TLIF). Post-operative recovery was complicated by a surgical site infection requiring IV antibiotic therapy and an additional 3-week hospitalization. It is important to note that the pre-operative imaging clearly demonstrated the extent of foraminal stenosis, and the surgical plan documented in Dr. Morrison's pre-operative notes references only discectomy without addressing the stenotic component.

Applying the differential diagnosis methodology outlined above, the following potential causes of Mr. Alvarez's continued post-operative symptoms and need for revision surgery were considered: 1. Inadequate Initial Surgical Decompression The pre-operative MRI clearly demonstrated both disc herniation and foraminal stenosis at L4-L5. The standard of care for a patient presenting with both pathologies requires addressing both components during surgical intervention. Clinical literature supports that failure to adequately decompress the neural foramen in the setting of documented foraminal stenosis results in persistent symptoms in 68-74% of cases (Epstein, N.E., "Foraminal and Far Lateral Lumbar Disc Herniations," Journal of Spinal Disorders, 2002). Dr. Morrison's operative report documents a microdiscectomy and foraminotomy; however, the post-operative imaging demonstrates residual foraminal stenosis that was radiographically unchanged from the pre-operative studies. This indicates that the foraminotomy performed was insufficient to achieve adequate neural decompression. 2. Recurrent Disc Herniation This was considered and ruled out. Post-operative MRI from March 18, 2024, demonstrates adequate discectomy at the L4-L5 level with no evidence of recurrent or residual disc herniation. The ongoing nerve root compression is attributable to residual foraminal stenosis, not recurrent disc pathology. 3. Normal Post-Operative Course / Expected Complication This was considered and ruled out. While post-operative radiculopathy can occur as a recognized complication of lumbar spine surgery, the radiographic evidence in this case demonstrates a specific, identifiable cause — residual foraminal stenosis — that should have been addressed during the initial procedure. A complication arising from failure to address known pathology does not represent an expected or unavoidable surgical risk. 4. Post-Operative Scar Tissue / Epidural Fibrosis This was considered and ruled out as the primary cause. While some epidural fibrosis was noted on the March 18, 2024, MRI, the predominant finding was mechanical compression of the L5 nerve root within the neural foramen. The temporal relationship — symptoms never improving post-operatively — further supports inadequate decompression rather than delayed scar formation.

Based on my review of the medical records, imaging studies, clinical literature, and application of the methodology described above, I hold the following opinions to a reasonable degree of medical certainty: Opinion 1: The standard of care required Dr. Morrison to adequately address both the disc herniation and the foraminal stenosis at L4-L5 during the March 15, 2024, surgical procedure. The pre-operative imaging clearly identified both pathologies, and the clinical literature establishes that failure to decompress a stenotic foramen in the setting of documented nerve root compression constitutes a departure from accepted surgical standards. Opinion 2: Dr. Morrison's failure to perform an adequate foraminotomy during the initial surgery was the proximate cause of Mr. Alvarez's continued post-operative radiculopathy and the necessity for revision surgery on June 22, 2024. The post-operative imaging confirms that the residual foraminal stenosis was the source of ongoing nerve root compression, and this pathology was present and identifiable at the time of the initial surgery. Opinion 3: Had adequate decompression been achieved during the March 15, 2024, procedure, it is more likely than not that Mr. Alvarez would not have required the revision fusion surgery, thereby avoiding the associated surgical site infection, extended hospitalization, and prolonged recovery. Opinion 4: The surgical site infection following the June 22, 2024, revision surgery, while a recognized risk of any surgical procedure, represents a harm that would not have occurred but for the need for revision surgery occasioned by the inadequate initial decompression. I reserve the right to supplement or amend these opinions based on additional materials or information that may become available.