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Physicians involved in pain management should be aware that there are many legal issues involved in the practice of pain management. Some patients who present to pain management centers may be involved in litigation or compensation cases. The impact of these issues on patient outcome is controversial. Patients with pain often are labeled “difficult” because of their responses to the stress of their pain. Furthermore, there is a widespread perception that anesthesiologists working in pain management centers are at a greater risk of being sued for malpractice than those working in the traditional operating room setting.


The available information, however, does not support this perception. For example, during the period 1971 to 1982 in Washington State, of 192 malpractice claims against anesthesiologists, 56 involved regional anesthesia, but only one (for a pneumothorax during stellate ganglion block) involved pain management.1 Data from the claims files of the Risk Management Foundation of the Harvard Medical Institutions shows only one anesthesia pain management claim during a recent 10-year period. In this claim, a man received a corticosteroid injection for meralgia paresthetica. Shortly after leaving the hospital, approximately 50 minutes after receiving the injection, he became dizzy. He returned to the pain clinic and fell, allegedly sustaining a back injury that caused permanent residual pain. The claimant alleged a failure to obtain informed consent and that the physician did not advise him to remain for observation for adverse reactions. The claim was resolved without a lawsuit.


The database of the American Society of Anesthesiologists Closed Claims Project shows that while the proportion of anesthesia malpractice claims involving nonoperative pain management is fairly low, it is increasing over time, from 2% of all claims in the 1970s to 8% of all claims in the 1990s. In a review of the database of closed claims, the most common injuries were pneumothorax, nerve damage, headache, and back pain. Claims for very serious complications such as brain damage or death represent a small but not insignificant fraction (10%) of the claims. The median payment for operative claims was much higher than the payment for nonoperative pain management claims ($100,000 vs $16,250). The likelihood of payment for a claim was similar between the two groups, as was reviewer judgment of appropriateness of care.2


Exposure to the risk of a malpractice claim will vary with the degree of a physician’s involvement with pain management and the type of procedures performed. The greatest risk for major claims appears to be associated with the administration of ablative nerve blocks.3–5


One moderate-sized pain management center in a university teaching hospital doing approximately 1000 procedures (nearly all injections) annually had the following distribution of case mix: lumbar epidural steroids, 66%; epidural narcotic catheters, 1%; transcutaneous electrical nerve stimulation (TENS), 2%; stellate ganglion, 6%; facet, 3%; and blood patch, 1%. Only a few blocks performed during this period were neurolytic. Therefore, this pain center, and other pain ...

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