12: Drummers Drumming (Nov. 2014)

Spinal epidural abscess - the first case story

You're a doctor, not a prophet. Jury agrees.

Facts: A 69 yo man presents to the ED with recurrent low back pain after lifting heavy objects out of his truck. His x-ray shows only DJD, so he is discharged with pain meds to f/u with his primary physician, which he does. He returns to the ED 8 days later with pain in the shoulder and back plus new onset jaundice and rash on one arm and both legs. A complete spinal MRI is done, showing only lumbar discitis and a psoas abscess. He is admitted and treated with antibiotics, but develops left arm deficits 2 days later and is transferred. A repeat MRI now shows a cervical epidural abscess. Despite surgery he is left with permanent loss of use of his left arm.
Plaintiff: You should have done the MRI on my first visit, not my second.
Defense: The diagnosis and care was reasonable. The MRI that we did on your second visit showed no abscess anyway. And you had no indication for an MRI on your first visit. If it was negative on your second visit, it would certainly have been negative 8 days earlier.
Result: Jury verdict for defense.
Takeaways:
1. SEA is rarely diagnosed on first presentation. Unless there are strong indications or multiple risk factors and findings, missing an SEA on the first ED visit is rarely negligent.
2. SEA was clearly considered on the 2nd visit, documented and a full spinal MRI done. We can't explain why it showed an abscess 2 days later, but it did.
3. As in up to 30% of cases, the source of the infection was not found.
4. We're physicians, not prophets.
Source: Campbell v Emergency Physicians of Central Florida

11: Pipers Piping (January, 2015)

Spinal epidural abscess

Take a history. Do an exam. Don't rely on "incidentaloma"

Facts: A 44 yo previously healthy man develops severe mid-back pain while at work. He presents to the ED, is treated symptomatically and released. Two days later he returns with pain in his "low back." Again he is symptomatically treated and released. Only a few hours later he returns a third time, now using a cane to walk. A lumbar-only MRI is done and shows foraminal narrowing. Assuming this explains his [non-radicular] symptoms, he is again discharged and returns a fourth time the next day, now with L leg weakness and urinary retention. He is admitted and a neurosurgeon finds that no surgical emergency exists, ascribing the urinary retention to the patient's opioid pain med. On the third hospital day he is found paralyzed below the waist. A full-spine MRI reveals a large thoracic spinal epidural abscess. Despite surgical drainage, he is left with a neurogenic bladder/bowel and right leg weakness. The source of the infection is felt to be dental work done 2 months prior.
Plaintiff: You missed my diagnosis. The lumbar-only MRI was inadequate. Foraminal narrowing would not explain my symptoms. Surgery should have been done earlier. Now I'm partially paralyzed and need a catheter.
Defense: Your symptoms were not classic. You looked well and had no fever. Earlier surgery wouldn't have changed the outcome.
Result: Mediation with confidential settlement for unknown amount, likely to have been in the 7 figures.
Takeaways:
1. Patients often associate the pain from an SEA with recent trauma. That does not lessen the responsibility of the physician to consider other options.
2. Despite defense claims that the presentation was not "classic," this IS a typical presentation of a spinal epidural abscess. The classic triad of fever, spinal pain,and neurologic findings occurs in only about 10% of cases, at which point, even as noted by the defense, it is too late to matter.
3. SEA is the subject of far too many lawsuits. Multiple visits for back pain in a previously healthy person should trigger suspicion, which should trigger a CRP/ESR. This alone proves one has thought of SEA in one's differential.
4. If highly suspicious due to risk factors, symptoms, exam or an elevated CRP/ESR, an MRI of the entire spine is indicated. A gadolinium contrast MRI is even better.
5. Bowel or bladder symptoms (as in this patient) should trigger an early MRI.
Reference: Spinal Epidural Abscess Clinical Presentation. Medscape eMedicine. Huff JS. Updated: Jul 12, 2018
Source: John Doe v. Anonymous - Washington. Personal communication.

10: Lords A-Leaping (May, 2015)

ANOTHER missed spinal epidural abscess

Pay attention to test results

Facts: A 44 yo male with recent interferon treatment for Hep C and a prior hx of neck surgery with hardware sees his PCP for new onset headache, photophobia and URI sx. Neck is tender and lab shows only abnormal liver enzymes. He is discharged with OTC analgesics. He is seen in the ED 3 days later when slightly worse sx and again discharged. He returns to his PCP 4 days later, with worsening HA, N/V and photophobia and is given oxycodone. When next seen in the hospital's Urgent Care Clinic, he has a temp of 101.4, hallucinations and neck stiffness. He is sent to the ED by ambulance for suspected meningitis. An LP shows "cloudy" CSF, 692 WBC (80% polys), low glucose and high protein but no organisms. He is diagnosed with viral meningitis and sent home with anti-emetics, MS-Contin, pending blood culture and no antibiotics. The next morning two blood cultures show staph aureus, but the CSF culture is negative. He is called to return to the hospital and admitted with a diagnosis of staph aureus meningitis. After 2 days in the hospital, he develops increasing lower body neurologic symptoms including urinary incontinence and retention. A cervical MRI is finally done and shows a spinal epidural abscess in the area of his surgical hardware. He is left quadraplegic/paretic and a lawsuit is filed.
Plaintiff: You should have admitted me and treated me with IV antibiotics as soon as you saw the CSF results. They were grossly abnormal and consistent with a bacterial, not viral, infection. You didn't even give me antibiotics when you sent me home with pending blood cultures. I had risk factors for SEA and you dismissed them. You should have done an MRI and found my abscess before it was too late. Now I'm disabled and can't work.
Defense: You had symptoms for 2 1/2 weeks. They weren't the classic triad for SEA. We treated you with antibiotics in the hospital.
Result: Confidential large settlement after 5+ years of litigation.
Takeaways:
1. Staph is the most common cause of SEA and a rare cause of meningitis.
2. The CSF was grossly abnormal and inconsistent with viral meningitis.
3. A negative CSF culture with positive blood cultures is not bacterial meningitis. 4. After 2 weeks of symptoms, a patient with staph meningitis would be dead and a patient with viral meningitis recovered. So what's left? Spinal epidural abscess, especially in immunocompromised patients with spinal hardware.
Because SEA is serious and so often missed, remember:
The common features of SEA are:
* Gradual onset, usually unrelated to a specific incident.
* Vague constitutional symptoms. Early neurological complaints range from tingling, numbness, proprioception issues, etc. to classic cauda equina syndrome.
* A sense of sincere concern by the patient as opposed to drug-seeking behavior. Patients - even drug seekers - seem to know that something is very wrong.
* Risk factors, like recent surgery, spinal hardware, dental work, IV drug use, immunocompromise, or diabetes.
* Fever and mildly elevated WBC.
* ESR and/or CRP are almost always elevated.
* Repeat ED or PCP visits over a short period. The diagnosis is almost never made on the first visit.
* Abnormal spinal fluid, which may or may not grow an organism
* Positive blood culture. (If blood culture is done, antibiotic coverage is appropriate pending results.)
* Finally, if there’s even a remote possibility of the diagnosis, document why you’ve eliminated it from the differential. If you can’t eliminate the diagnosis with a CRP/ESR, get an MRI of the entire spine. Half of litiigated cases found the abscess at a level not imaged in the first MRI.
Source: John Doe v. Anonymous - Washington. Personal communication.

9: Ladies Dancing (March, 2016)

And another missed spinal epidural abscess (SEA)

Good documentation and patient factors preclude a lawsuit

ESR and/or CRP are your best friends if SEA is even remotely possible

Facts: 52 yo female sees her PCP seven times for back pain from June into August of 2015. Fever is noted only on the 3rd visit in late June and patient is strongly urged to go to the ED for evaluation. She declines. A PCP note in July says she has “no sx of cauda equina syndrome.” No fever on any other visits, and no significant risk factors present. Is known to overuse opioid pain meds and demands them on every visit. Relatively uncooperative and refuses to sign release of records for a secondary clinic that she also visits. She is using a walker when seen in the ED on August 11, and an MRI is recommended “if symptoms persist.” On August 14 (a Friday) she complains to her PCP of stress incontinence, poor balance, and “my legs never felt like this before.” An MRI of the spine is ordered that day but never done. She goes to the ED a second time on August 20th after 9 days of urinary symptoms, lower extremity weakness, burning and balance issues. An MRI now shows an extensive SEA. Despite immediate surgery she is left a partial paraplegic dependent on others for much of her ADL’s. An attorney is consulted who refers the case to an expert for review.
Plaintiff: I had symptoms for almost 3 months and none of you (PCP, secondary clinic or ED) figured out why my back hurt so much and why my legs weren’t working right. Now I’m paralyzed and can’t do the things I used to be able to do.
Defense: I told you to go to the ED when you had a high fever - and you refused. We did a urine drug screen that showed you were already taking opioids I did not prescribe. You got better for a while. I documented that I considered cauda equina syndrome but saw no evidence for it. You were uncooperative in your own care, more interested in getting narcotics than finding answers to your problem. Even during the last 2 weeks you didn’t get the MRI I ordered. And there is no guarantee that your outcome would have been different had we found the cause a week or two sooner.
Result: Case considered too complicated to persuade a jury that her physicians were negligent. There were also issues of state and federal jurisdiction due to involvement of a federally funded clinic.
Takeaways:
1. As previously discussed in reviews of other SEA cases, a simple ESR or CRP test can quickly sort out the SEA patients from the drug seekers and malingerers. The test is almost universally grossly elevated in patients with an SEA. Doing the test shows you were thinking of SEA.
2. Those with high ESR or CRP - or simply elevated risk - should have a COMPLETE spine MRI, because the abscess is frequently located in an area distant from the point of pain.
[Editor's Note: We are approaching a dozen missed spinal epidural abscesses in Washington State in the last 5 years. That's tens of millions of dollars in settlements. Hopefully no reader of this publication will ever miss one.]
Source: Jane Doe v. Anonymous - Washington. Personal communication.

8: Maids A-Milking (July, 2016)

And another missed SEA

Failed communication with radiologist leads to $12.5 million verdict

Facts: A 53 yo male is seen in the ED for left-sided neck pain and tingling in his left arm. He is admitted to a cardiologist and develops fever, urinary retention and difficulty walking. An infectious disease consultant suspects a cervical SEA, orders an MRI and consults a neurologist. An SEA is present but the radiologist misses it and the neurologist, while suspecting spinal cord compression, fails to view the imaging himself. The patient worsens and is transferred to a higher level of care where the abscess is discovered - too late. Despite surgery he is left quadriplegic with loss of bladder control and sexual function.
Plaintiff:
* Radiologist: You clearly missed the cervical epidural abscess on my MRI.
* ID doc: You ordered the MRI for a reason. You should have talked to the radiologist and the neurologist instead of just trusting his report.
* Neurologist: You should have looked at the MRI yourself and seen the abscess.
Defense:
* Radiologist: Nothing I did or didn’t do caused the plaintiff’s injuries.
* ID and Neurology: We aggressively treated the patient. Nothing would have changed the outcome.
Result: $12.5 million plaintiff award after 4 hours of deliberation following a 2 week trial with 9 experts for the plaintiff and 12 for the defense. 2/3 of the award was against the radiologist, 1/3 against the neurologist. Other defendants were dismissed or found not responsible.
Takeaways:
1. Communicate your suspicions directly with radiology when you order an MRI to r/o an SEA.
2. View the films yourself.
3. If SEA is suspected and you don’t see it at the level you expect, image the whole spine.
4. Docs usually get a pass for not picking up an SEA on a first visit, but must always think of this in every patient presenting a second, third or fourth time with new onset and worsening spinal pain and symptoms.
Source: DelGrosso v. Friedman et al., Delaware Co., Pennsylvania, August, 2015.

7: Swans A-Swimming (July, 2016)

An egregious miss of another SEA (Getting a bit old, eh?)

Listen to the story, examine rationally and document correctly

Facts: A diabetic adult female presents to the ED with leg weakness and heaviness. Gait, reflexes or leg strength are documented only in a nursing note that says “Up to BR, steady gait.” WBC is 15,700, blood glucose is 236. Discharged with a dx of pneumonia [?] on azithromycin. She goes to a 2nd ED 3 days later with R sided back px radiating to her abdomen. Exam is recorded as “patient moving all extremities, no gross neurological deficit.” Glucose is now 377, WBC 10,960, d-dimer normal and a kidney CT is normal. Is given Dilaudid for pain and switched to TMP/SX. Discharged “ambulatory” to see PCP in 3 days for “possible outpatient MRI.” Returns to 2nd ED 3 days later, still with R sided mid-back pain and leg numbness. “No apparent cauda equina syndrome” appears in chart as computer-generated macro [“he” is used and “hypernatremia” is recorded instead of “hyperglycemia” /cp.] Again, no gait is recorded. She is again discharged but immediately falls upon arriving home. She calls 911 and is returned to the same ED. CC says "mid-back pain" but ROS says both “negative for back pain" and "+ back pain,… no focal weakness… respirations 146.” No temp is recorded. Exam records back tenderness (now L, not R), decreased sensation to umbilicus, inability to walk, “rectal tone present.” WBC is now 17,600 w/ bands, CRP and ESR are elevated, and a lumbar-only MRI to r/o epidural abscess is negative. She is transferred 8 hours later to a tertiary center where she is admitted with “Sudden inability to ambulate” and loss of leg sensation. Focus remains on “pneumonia” [?] as cause of elevated CRP/ESR. Referring ED's concern for “epidural abscess” is apparently dismissed based on negative lumbar MRI. The next day a neurologist records that “presentation is suggestive of embellishment or functional disorder” and orders an EMG, which is non-diagnostic. An MRI of the entire spine on the 2nd hospital day finally shows a thoracic spinal epidural abscess. The patient is left a paraplegic and a lawsuit is filed.
Plaintiff: You should have made the diagnosis on my first ER visit. Leg weakness, no neuro exam, elevated WBC, I’m diabetic, and you assumed I had pneumonia? What were you thinking? I then had 2 ED visits at another hospital. Your computer-generated records make you look ridiculous and can’t be believed. My numbness indicated a thoracic level process but you only did a lumbar MRI. You thought I was faking it! Now I’m paralyzed because of your incompetence.
Defense: Ah, well, we think we did the best we could given the circumstances. Maybe we should just settle this.
Result: Multi-party pre-trial settlement for undisclosed amount likely to have been in the seven figures.
Takeaways:
* Readers of this newsletter should be shocked at this. [For every "frivolous lawsuit," there are at least twice as many horror stories like this one./cp]
* If your diagnosis is "pneumonia," make sure your documentation supports it.
* Avoid pre-conceived notions, anchoring bias, diagnostic momentum and confirmation bias, which are rampant in this case.
* If you do a test like a CRP or ESR, don't disregard the result or attribute it to your anchored dx.
* Do and document at least a basic neuro exam.
* For any neurological complaint, a thorough description of the patient's gait is the best single neuro test, especially for SEA. ("Road test" in ED parlance.)
* Never use the words "embellishment"or "malingering" in a medical record.
* Suspect SEA at levels other than the location of the pain or level of neurological symptoms. Image the whole spine if SEA is suspected.
* The EHR can be your friend or your enemy. In this case, entry errors made caregivers look ridiculous. Does your EHR output really match your hx and exam? Does it support that you actually saw the patient, or only that you clicked a few buttons/boxes - and maybe the wrong ones?
Source: Jane Doe v. multiple defendants, Washington State

6: Geese A-Laying (July, 2016)

Heroin addicts are at high risk for SEA

Jury verdict for $6.6 million will buy a lot of heroin

Facts: A 44 yo male heroin addict arrives by ambulance c/o a 3 day hx of severe back pain with inability to breathe. He has a fever, tachycardia, nausea and vomiting. WBC and glucose levels are elevated. A blood culture is done. He is diagnosed with back pain and narcotic withdrawal, despite admitting to having just used heroin that same day. He is discharged with an rx for Percocet and told to see a family physician in 2-3 days. The BC returns positive but the patient is not informed. He is unable to find a physician and awakens paralyzed from the chest down 3 days later. He is taken back to the hospital, diagnosed with a likely SEA and transferred to Temple U. Hospital. Surgery is done but too late to prevent ongoing paralysis. A lawsuit is filed against the ED physician and hospital.
Plaintiff: I'm paralyzed from my chest down because of your negligence. I didn't have withdrawal symptoms. I had several risk factors for SEA. You should have told me I had a serious infection. You could have fixed me if I'd known I had a serious problem. You dropped the ball. According to your own policies, you should have called the police or social services to find me. Your records show that you even verified my contact information before I left.
Defense: Your diagnosis was consistent with your presentation. You told me you'd been off heroin for several days. You admitted to chronic back pain and have bipolar disorder, hepatitis B and C, and are addicted to drugs and alcohol. Yes, I knew you were at high risk for infection. I did a blood culture, but the lab only gave the report to a nurse. The hospital tried to call the number you gave us, and even sent a certified letter to your address. You were still OK 2 days later and you could have come back then if you weren't better - just as your instructions said. We could have saved your legs then. You even used heroin again before you called 911 to return to the hospital. And your phone records show you made and received other phone calls during that time.
Result: $6.6 million settlement prior to verdict after a 9 day trial, 64% of amount against the hospital.
Takeaways:
* IV drug abuse is a major risk factor for SEA.
* Even those with chronic pain can have an SEA. Don't pre-judge patients.
* Use the ESR/CRP to help make the diagnosis.
* If you order a blood culture on a patient with back pain, you better have a well-documented reason for not admitting them and covering them with antibiotics until the culture returns.
* Follow your hospital policies and use common sense if a blood culture returns positive.
Source: Walker v. Jeanes Hospital et al., Philadelphia Court of Common Pleas. The Legal Intelligencer

5: Golden Rings (September, 2018)

Was it the spinal epidural abscess or a spinal cord infarct?

Whatever, it cost an infectious disease doctor $16.2 million

Facts: A 58 yo diabetic female CPA presents to the ED with acute, new onset back pain. She is diagnosed with non-traumatic back pain and discharged with symptomatic care. She returns 8 days later with continued back pain and altered mental state. She is admitted with a dx of DKA, acute renal failure and severe sepsis. On hospital day 5 her ID specialist notes increasing leg weakness and orders an MRI which reveals a low thoracic SEA. Decompressive surgery is done immediately but she remains paraplegic and needing continuous care at discharg a month later. A lawsuit is filed against her ID doctor and the hospital.
Plaintiff: I’m diabetic. I had unexplained back pain and sepsis. The nurses did not monitor my neurological signs and did not report my condition to physicians in a timely manner. You should have thought of SEA earlier and done an MRI when I was admitted - before I became paralyzed. That was the source of my sepsis. Now I'm in a wheelchair and can't work.
Defense: Yes, you had an abscess, but that wasn’t what paralyzed you. Your spinal cord was not compressed, but instead suffered an infarct due to the abscess. An infarct won't get better when the abscess is removed. You arrived at the hospital with life-threatening sepsis, kidney failure and diabetic ketoacidosis. Multiple physicians and consultants treated you appropriately for your infection. Your care was excellent. Your paralysis was the result of the sum of the devastating effects of your infection, not a delay in diagnosis of your SEA.
Result: $18 million jury verdict against the attending ID physician after a 7 day trial and only 4 1/2 hours of deliberation. The hospital was found to be 10% liable but had been dismissed from the case before trial. That amount is likely to be more than the ID physician's med mal cap.
Takeaways:
* Diabetics are at much higher risk of SEA. So are alcoholics, drug abusers, patients with spinal hardware and those who are immunocompromised.
* Note that the original ED physician was not named in the suit. The first doctor to see a back pain patient with an SEA is almost always given a pass if no neurologic symptoms are present, but repeated visits for new back pain are red flags.
* Think of SEA in all patients with back pain, especially those with risk factors.
* If you think SEA is even remotely possible, a CRP or ESR will be elevated in nearly 99% of cases. If not elevated, doing the test proves you thought of it.
* Always look for primary sources of sepsis.
* A spinal epidural abscess can cause sepsis. Conversely, sepsis can cause a spinal epidural abscess. In this case, we don't really know which.
* Other primary sources of SEA are UTI, dental abscess and skin infections, among many others.
Source: Public records of Simmons v. Candler Hospital, Chatham County (Georgia) Superior Court, No. STCV1600837-FO.
Reference: Spinal Epidural Abscess. Huff JS. Medscape eMedicine. Updated Jul 12, 2018.

4: Calling Birds (December, 2018)

Spinal epidural abscess: How many more?

Let's stop missing this easy-to-make diagnosis

Facts: An adult female with a BMI of 54 is seen in the ED with a 2 wk hx of increasing low back px, numbness and tingling radiating into her R hip and leg. She attributes this to falling when a chair broke at work 4 weeks ago. Other than a lumbar fusion 20 years prior (no hardware), the remainder of her H & P are unremarkable. Plain x-rays are normal and she is discharged with appropriate instructions. A week later she is again in the ED with worsening sx despite being prescribed a Medrol Dosepak by her PCP in the interim. Exam including rectal tone is normal except for decreased sensation lower R leg. WBC is 19,400 w/13,600 polys, ESR is 60 and CRP 3.5. She is again discharged with no comment on the abnormal lab findings or why an MRI was not done. Later discovery suggests that the patient was too large for the hospital's MRI machine. The following day she is seen at a different hospital with new onset bowel/bladder incontinence and numbness of her R foot. An MRI is ordered for "R/O Fracture" and shows a small L5-S1 SEA. A prior hx of SEA following an earlier surgery is now noted. After decompressive laminectomy she is left with R leg weakness, numbness and occasional incontinence but is able to walk. An attorney is consulted.
Plaintiff: You should have done an MRI when you saw my WBC, ESR and CRP. You would have seen the abscess and you should have admitted me then and drained the abscess. My EM expert says that if I had been treated earlier, my outcome would have been significantly better.
Defense: Although there appears to be negligence for failing to respond appropriately to the abnormal lab results, our surgical experts believe her outcome would have been the same even with earlier surgery. Your client's damages are minimal and unrelated to any negligence.
Result: With only moderate damages and causation at issue, a pre-trial settlement could not be reached. The attorney chose not to pursue the case into litigation for "logistical reasons."
Takeaways:
* This is a classic story of a spinal epidural abscess.
* A more complete history would have earlier revealed a prior episode of SEA and should have triggered suspicion of a recurrence.
* Doing a CRP/ESR to r/o SEA is a quick screen and the standard of care for progressive back pain, especially when risk factors are present. Those risk factors are most commonly surgical hardware, diabetes, alcohol/drug abuse, immuno-compromise, dental abscess or soft tissue infection.
* A CRP/ESR, if normal, is evidence that SEA has been considered. This is a strong defense to a claim of failure to diagnose.
* If CRP/ESR is abnormal, the standard of care is an emergent MRI. That was not done in this case.
* The absence of a "high capacity" or "open" MRI machine for a larger patient is not an excuse. If SEA is suspected, transfer to a facility capable of doing the MRI is the next step.
* SEA is a simple diagnosis to make. All one must do is think about it. Then get a CRP or ESR, note the result and take appropriate action.
* Failure to make this dx threatens both patient and provider with a disastrous outcome - the former life-changing paralysis and the latter a life-changing medical malpractice lawsuit.
References: Too many cases, depressingly similar, have already been presented in this newsletter. Please see the references mentioned in the cases above and below.

3: French Hens (November, 2019)

And ANOTHER missed spinal epidural abscess! (It's a long story.)

Multiple missed opportunities leaves patient wheelchair-bound

Facts:
* A 68 yo male with diabetic neuropathy and a foot ulcer growing MSSA falls at home and develops back pain.
* 2 1/2 weeks later he sees his PCP for a routine exam. His doctor documents significant and worsening thoracic back pain with no prior hx of same. A CXR shows nothing unusual in the T-spine. He is treated with Ultram, and told to return if worse.
* 3 days later he calls the office for the x-ray results and is prescribed Celebrex.
* 5 weeks after injury he calls his PCP again. A lumbar MRI is ordered but later denied by pt's insurer, apparently because pt. is required to have PT before an MRI is approved.
* 1 week later he sees his PCP with 8/10 pain. A note says that he is scheduled the following day for the lumbar MRI previously ordered. A followup appointment is scheduled in 6 weeks.
* His MRI is apparently denied for lack of insurance approval.
* Pt. repeatedly calls his PCP for an explanation and is sent to PT, which he is unable to do because of pain.
* 7 weeks post "injury" he sees his PCP a 3rd (?4th) time. The PCP agrees to investigate the MRI denial. Treatment is unchanged.
* A week later he calls his PCP with 10/10 pain. A podiatry note cancelling an appt. for that day indicates he is to have his MRI in 3 days and might be admitted.
* On the day of the MRI appointment, the pt. presents to the ED because of intractable pain and misses his scheduled imaging appt. Neuro exam remains normal. No differential dx is recorded. An L-spine x-ray is unremarkable. The EP contacts the PCP, is advised to re-order the MRI as an outpatient and f/u with the PCP.
* 10 more days later, and 2 1/2 months following "injury," the pt. has a thoracic MRI. Pt. calls his PCP for results that afternoon with no response.
* The next morning, radiology calls the ED to advise that pt. has a thoracic SEA. The pt. is called to return to the ED. On arrival he is said to be "walking" and "neuro WNL" with limited ROM of T-spine. Transfer to a higher level of care is arranged.
* Pt. deteriorates enroute. On arrival at the tertiary hospital, his ESR is 87. Despite surgery he is left paralyzed below the waist. The SEA grows the same MSSA as is in the foot ulcer that was being treated 2 1/2 months earlier. Following discharge he seeks legal advice and a lawsuit is filed against the PCP, hospital and ED physician.
Plaintiff:
My PCP:
* failed to develop a differential diagnosis that would explain why I needed an MRI
* had a low level of concern despite increasingly severe pain in a pt. with no prior hx of back problems or chronic pain
* failed to do a basic CRP/ESR demonstrating consideration of an SEA
* failed to connect the open staph wound on my foot with a possible SEA
* failed to timely obtain for me the proper imaging
* failed to advocate for me with my insurer
* allowed at least 4 weeks to pass before my MRI was done
* dissuaded the ED physician from obtaining an emergency MRI, resulting in a 10 day delay in the study
* failed to follow up on the MRI on the day it was finally done.
* caused me to be paralyzed for life from the waist down.
The ED physician:
* failed to develop a differential that would have justified an emergency MRI, especially after an MRI had been twice ordered by the PCP but never completed - and the MRI machine was right down the hall.
* failed to obtain a CRP/ESR to rule out SEA
* succumbed to the PCP's advice that an O/P MRI was sufficient when he did not know for certain if and when the study would be done, resulting in a 10 day delay
* allowed himself to be reassured by a non-diagnostic lumbar spine plain film
The hospital:
* You are responsible for the actions of your physicians. Regardless of their employment contracts or specialty, physicians working in your hospital are perceived by patients as your agents.
The insurer (not a defendant):
* You failed to communicate with the PCP regarding an order for a necessary test. A phone call from a physician, not a fax from an RN, PA or LPN reviewer, is appropriate when a study is denied. (In this case, denial may also have been because a lumbar MRI was ordered for a pt. with thoracic px.)
Defense:
PCP: I ordered the right test at the right time. The insurance company made it hard to get it done. The patient was fine when he was in the ER. Doing the MRI as an O/P was appropriate, and in fact he did well for another 10 days.
ED Doc: Ditto.
Hospital: None of the docs are our employees.
Insurer: We communicated our thoughts appropriately. Re-check the PCP's records. (That evidence was not presented until trial.)
RESULT: Defense verdict after 2 1/2 years of litigation, a 2 week trial and 3 1/2 hours of jury deliberation. The presence of multiple defendants (the PCP died during litigation) and the defendants all engaged in finger-pointing may have made it easier for the jury to throw up their hands and find for the defense.
Takeaways:
* When ordering an MRI for back pain, specify the reason, e.g., r/o spinal epidural abscess. "Back pain" is insufficient. Help our radiology colleagues help us and our patients.
* If an ordered test is denied by an insurer, find out why and advocate for the pt.
* As ED docs, we have immediate access to imaging (and other tests). We do so without regard for insurance issues. Putting our patients ahead of the financial concerns of insurers is our duty.
* Remember the value of a CRP/ESR to make the dx of SEA or demonstrate that the dx was at least considered.
References:
1. Spinal epidural abscess: clinical presentation, management and outcome. Curry WT et al. Surg. Neurol. 2005;63(4):364
2. Spinal epidural abscess. Moore D. OrthoBullets online. 26 July 2017
3. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. Davis DP et al. JEM 26(3):285-291, 2004.
4. Spinal epidural abscess: A review with special emphasis on earlier diagnosis. Bond A, Manian F. BioMed Res. Int. Dec. 2016.

2: Turtle Doves (August, 2020)

Great catch of a spinal epidural abscess (SEA)

Atypical history, no risk factors, first ED visit

Facts: An adult female is unable to sleep due to severe back px, spasms and swelling for 3 days. She drives herself to the ED in the pre-dawn hours. There she requires a WC to triage. Px is worse in the L lumbar region with px, numbness and cold sensation in her L leg. She also describes intermittent inability to move her L leg. ROS is negative for fever, N/V, GU sx, or recent infection. Pertinent PH is positive for agoraphobia, bipolar disorder and PTSD post combat. PH is negative for diabetes, alcoholism, IVDU, immune compromise or surgical hardware; she later acknowledges a dental problem of uncertain importance. OTC px meds have not helped. SH/FH is positive for mother's severe back pain and death from ALS. On exam, she perseverates, answers some questions inappropriately and is a generally poor historian. VS are normal. She has tenderness only in the L lumbar area. Her neuro exam shows no leg weakness but absent L patellar and ankle reflexes. She refuses to consent to an MRI, so is given Toradol IM and lorazepam and her disposition deferred to the day doc at the end of shift. Labs are drawn and are all normal except for a WBC of 16,200 w/ 83% polys. Seven hours post arrival, the day doc notes her temp is now 38.1; it rises to 39.1 only 30 minutes later. An SEA is considered, she is started on vancomycin and given MS for pain. She also finally agrees to a non-contrast thoracic/lumbar MRI which shows a presumptive SEA from T-2-T11, confirmed by contrast MRI. She is taken emergently to the OR for decompression 12 hours after arrival. She is discharged to a rehab facility and is walking without assistance 4 weeks later.
Plaintiff: No lawsuit is filed. SEA was considered, found and appropriately treated.
Defense: Excellent care despite patient being atypical, difficult and uncooperative.
Result: Keeping SEA top of mind, even in an atypical and uncooperative pt. led to the desired outcome.
Takeaways:
* SEA was considered by both docs. This is key to making the diagnosis and should be the first thing to consider when seeing one of our daily ED patients with back pain. A minimum level of suspicion is all that is needed to avoid missing a life-changing diagnosis. H & P can usually eliminate if from the differential.
* When the going gets tough, the tough keep going. Persistence matters. Don't give up on difficult patients.
* Consider transferring care to or consulting with a colleague when the picture is unclear and you are stymied.
* The "classic triad" was not present on arrival; there was no fever, and neuro sx were inconsistent.
* The elevated WBC was a good clue.
* A CRP/ESR could have been done, but the decision was made that she would need the MRI regardless. Either a CRP or ESR would likely have been markedly elevated.
Reference: Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Bhise V, Meyer A, Singh H, Wei L. Amer J Med 130(8), March 2017.
[Editor's Note: The above reference is excellent but says little about a common “red flag”: escalating ED or clinic visits for back pain over days to weeks. The dx is easy to make if one thinks about it. It’s ruled out with 99% sensitivity if a CRP or ESR is normal - and you'll have proof that you included SEA in your differential. /cp]

1: And a Partridge in a Pear Tree (Aug. 2020)

One more for the road. Don't be next.

Too many SEA's still being missed.

Facts: Three ED visits for back pain in 12 hours. Note the biases and delays.
* ED Visit 1: A female in her early 30's presents to the ED with 6/10 mid-back px radiating to her chest. She relates the onset to lifting her daughter’s carseat out of the car 2 days prior. Her ROS includes slight SOB, no cough, slight nausea and no fever. A CXR is ordered and suggests a subtle pneumonia or infarct. A chest CT is then done and finds only “airspace disease” and subtle atelectasis. She is given Dilaudid 1 mg, Zofran 4 mg, Toradol 30 mg and Ativan 0.5mg IV while in the ED, and discharged with a diagnosis of “pneumonia” with prescriptions for azithromycin and Vicodin.
* ED Visit 2: She returns to the ED 11 hours later with 6/10 back px and bilateral leg weakness, numbness, tingling and pain radiating to her chest. She says that the new symptoms started shortly after taking her first dose of azithromycin. On this visit absence of incontinence and fever is documented but so is a history of bipolar disorder. On exam she is noted to be "anxious" and able to raise both legs against gravity. Sensation and reflexes are not documented. Physician notes “patient asking to go home.” She is switched from azithromycin to doxycycline and discharged with a dx of “paresthesias.” The discharge nurse records “Normal sensation from head to lower rib margin. Px 5/10. Pt reports MD will be discharging her home.”
* ED Visit 3: She returns 45 minutes later by EMS after falling at home and is now unable to move her legs except to withdraw to pain. Babinskis are positive and a bladder scan shows 500 cc of urine. An LP is done; CSF protein is 335. An MRI is ordered but not done for 3 hours, eventually revealing a spinal epidural abscess extending caudad from T-6. A neurosurgeon at the system's "mother ship" hospital accepts patient in transfer, but since no bed is available, transfer is delayed another 6 hours. She undergoes surgery later that morning but does not regain use of her legs. She consults an attorney and a lawsuit is filed.
Plaintiff: On my first ED visit you were more focused on my chest than my main complaint of back pain (anchoring bias.) Once you saw an abnormality on my CXR, you decided you'd struck paydirt, even when the CT you ordered didn't support your initial impression (confirmation bias). I didn't have "pneumonia." On the second ED visit you assumed my earlier diagnosis was correct, did not review my hx and didn't check my sensation or reflexes, even when the nurse wrote that my sensation was only normal to my lower rib margin (diagnostic momentum). This was not an azithromycin reaction (more anchoring bias). On both visits no one took a decent hx. No one did a thorough neuro exam or a rectal exam. No one had me walk. No one considered anything other than my chest complaints. When I returned by ambulance, you weren't even considering an SEA and did a risky LP before ordering an MRI. Everything took way too long. You accepted extended delays and had no sense of urgency. I was paralyzed and needed emergent surgery. Your loyalty to your hospital system's finances trumped my need for emergent surgery. You should have sent me to the nearby teaching hospital the minute you stumbled on my diagnosis and no bed was available in your own system. I would be able to walk today if not for everyone's negligence and delays.
Defense: The course of your paralysis was so fast that a secondary spinal cord infarct is by far the most likely cause. Earlier surgery would not have helped. We considered a primary neurological problem on your second visit and ruled it out. You were asking to go home. The delay of the MRI and transfer made no difference. Most studies show that outcomes are only worse if surgery is delayed more than 24 hours.
Result: After expert review supporting negligence and causation, the original attorney transferred the case to a law firm in another state for unknown reasons. The final chapter is unknown, but a pre-trial settlement would be expected. While the defense argument has weight, earlier diagnosis is always better and was possible in this case.
Takeaways:
1. Most often the first presentation gets a “pass.”
2. The second visit suggests that a neurological problem was considered but poorly evaluated.
3. Everyone agrees that “earlier surgery is better.” For SEA, "early" means immediate.
4. SEA’s rarely move this fast, so an untreatable secondary infarct is a very likely cause. A spinal cord infarct could have played a role, but the diagnosis should have been made earlier. If so, the infarct would not have happened; earlier surgery would have led to a better outcome.
5. Think SEA in all back pain patients. It can be ruled out on H & P alone, but consideration should be documented.
6. An ESR or CRP will almost always rule in or out an SEA. More importantly, the test shows that you considered it.
7. When you suspect an SEA, don’t do an LP until after a negative MRI. An LP done through an abscess can move the infection INTRA-dural.
8. WALK YOUR PATIENTS and document it. It's the best single neuro test one can do.
Reference: Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Bhise V, Meyer A, Singh H, Wei L. Amer J Med 130(8), March 2017. Free full-text download available at link.