Medical Malpractice Insights: Another missed spinal epidural abscess?

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

The Archives of MMI and emDocs both contain dozens of cases of missed spinal epidural abscess (SEA). Recently, an MMI reader made the diagnosis in an atypical presentation and attributed the good outcome to the multiple reminders from 5 years of reading case presentations. The case below is not that case, but is presented to again remind emDocs readers that SEA is an easy diagnosis to make if one thinks about it.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Another missed spinal epidural abscess (SEA)

Good documentation and patient factors preclude a lawsuit

Facts: A 52-year-old female sees her PCP seven times for back pain from June into August. She has no known risk factors for SEA but is known to over-use opioid pain medications and requests them on every visit. Fever is noted only on her 3rd visit in late June, at which time she is strongly urged to go to the ED for evaluation. She does not. A July note says she has “no symptoms of cauda equina syndrome.” She acknowledges being seen at a second clinic but refuses to sign a release of records and is generally uncooperative. On August 11 she presents to the ED using a walker. She is discharged with a recommendation for an MRI “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 but for unknown reasons is not done. On August 20 she returns to the ED with 9 days of urinary symptoms, lower extremity weakness, burning, and balance issues. An MRI now shows an extensive thoraco-lumbar 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. You refused. A urine drug screen in the clinic showed you were 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:

• A simple ESR or CRP can assist in evaluating for SEA patients, especially in drug seekers and malingerers. The test is almost universally “shockingly elevated” (an ID colleague’s words) in SEA patients.
• Doing the test is evidence that one is thinking of SEA, and if normal, is an effective defense should one later be found.
• Those with a high ESR or CRP, risk factors, or a high level of suspicion should have a COMPLETE spine MRI, because the abscess is often found to be distant from the point of pain or be present at multiple levels.
• Missed SEA’s number in the dozens each year nationwide. Making the diagnosis in time to prevent disability could avoid tens of millions of dollars in settlements and years of stressful litigation. Hopefully no emDocs reader will ever miss one.
• The reference below is excellent but glosses over one of the major signs of SEA: frequent or escalating visits for back pain, even in chronic opioid users.

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. https://www.researchgate.net/publication/315775432_Errors_in_Diagnosis_of_Spinal_Epidural_Abscesses_in_the_Era_of_Electronic_Health_Records