The Expert: Dr. John Cooney, an anesthesiologist with a specialty in chronic pain management, discusses his treatment of plaintiff’s complex regional pain syndrome, or CRPS.
Dr. John Cooney, a board-certified anesthesiologist with specialty training in chronic pain management, testifies as an expert in Preiser v. Choice Brands, a 2013 Florida products liability trial, in which the plaintiff claimed that she fell from her horse and injured her arm due to a defective leather horse bridle. The testimony here is centered on the treatment and complications of complex regional pain syndrome, a chronic condition occurring after injury to an extremity characterized by pain that is greater and lasts longer than would be expected by the injury that caused it. The exact cause is not well understood, but it is believed to result from abnormal inflammation or nerve dysfunction.
Dr. Cooney begins this video by discussing the process that results in complex regional pain syndrome moving from an upper extremity to a lower extremity or from one side to the other. This occurs due to “the sprouting of small nerve root connections…either in the thalamus or more likely in the spinal cord” which can cross the midline to effect the other side.
Treatment of moderate and severe complex regional pain syndrome involves procedures, medications, and physical therapy. Milder forms may be treated with medication alone. The procedure arm of treatment is what Dr. Cooney specializes in.
The nervous system of the body is composed of the somatic nervous system and the autonomic nervous system. The former controls muscle movements and the latter controls bodily functions. The autonomic system is further divided into the sympathetic nerves and the parasympathetic nerves which work to balance each other. Complex regional pain syndrome is a disease of the sympathetic nervous system which is usually manifested by excessive sympathetic nervous activity. As it applies to this case, this over activity can result in a cold extremity and burning pain sensations. The procedures that the doctor initially performs in general will inject a local anesthetic to temporarily diminish function of the sympathetic nervous system.
The sympathetic nerves generally follow the anatomic path of the somatic nerves, but injecting local anesthetic into both would disable the movement and create numbness of the extremity supplied by that nerve. Therefore when doing these procedures, the doctor will look for places where the sympathetic nerve briefly leaves the somatic nerve to form a cluster of sympathetic nerve cells called a ganglion. It is the ganglion that is injected to disable the sympathetic function of the nerve without effecting the other functions of that nerve. In this case, the stellate ganglion in the neck was anesthetized. The expert demonstrates the position and size of the ganglion with a prop.
This procedure will result in a sympathetic nerve block for only about six hours, but performed repeatedly, the temporarily diminished function will theoretically reset the sympathetic system within that ganglia to a more normal baseline. Unfortunately, this did not occur in this case and the patient’s symptoms persisted despite the sympathetic nerve block.
Dr. Cooney then attempted a “lesioning procedure” or “ablation of nerve tissue” which would damage the sympathetic nerve resulting in its dysfunction for six to twelve months. Eventually after this time, peripheral nerves like this recover, requiring repeat of the procedure. The procedure is known as a rhizotomy and the ablation is accomplished by damaging the nerve with a heater probe. This is repeated once a year and would help with her blood flow and sense of coldness in the extremity.
As a patient with complex regional pain syndrome ages, the condition will improve, but not disappear, over about ten years’ time. However, any trauma or surgery to the effected extremity or to another extremity will leave the patient at increased risk for development of complex regional pain syndrome in the newly damaged extremity or recurrence in the previously effected extremity. Precautions have to be taken to try to prevent this from occurring.
The expert clarifies that the purpose of his procedures is not to directly effect the strength of the extremity, but by improving the pain and cold sensation, allow the patient to better utilize physical therapy to help with that strength.
The video concludes with Dr. Cooney’s affirmation of the life care planner’s estimation of cost and frequency of future treatments for this patient. He anticipates treating her once a year with rhizotomy for several more years.
The expert’s clearly stated explanations obviously contributed to the jury’s verdict for the plaintiff in the amount of $4,850,000.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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