Emergency Medicine Claims Case Study: Spinal Abscess
March 1st, 2019
Janet McCrossen, BSN, RN
Spinal epidural abscess is a rare but potentially devastating condition that must be immediately identified and treated. This localized infection or accumulation of pus in of the epidural space of the spinal canal has an estimated incidence of only .2 to 2.8 cases per 10,000 each year. But when left untreated, the consequences can leave a patient severely disabled.
Though the condition is rare, physicians’ failure to diagnose spinal epidural abscess in the emergency department is a common cause of malpractice claims activity. The condition typically causes local or radicular back pain, percussion tenderness, and fever. If the abscess compresses the spinal cord, neurologic deficits (e.g., leg paresis, saddle anesthesia, bladder and bowel dysfunction) may develop.
Because rapid treatment is necessary to prevent or minimize neurologic deficits, clinical suspicion of spinal epidural abscess should be high. If spinal abscess is suspected, the physician should immediately perform an MRI or myelography (if MRI is unavailable), followed by a CT scan. When causing neurologic deficits, the abscess must be immediately drained through surgical intervention. Pus is then gram-stained and cultured, and the patient is treated with antibiotics that cover staphylococcus, anaerobes, and sometimes gram-negative bacteria.
Spinal abscess is usually caused by bacteria and can be a result of other infections within the body that spread through the bloodstream. Abuse of intravenous drugs is also associated with a higher prevalence of spinal abscess due to hematogenous spread of bacteria from contaminated syringes and needles. Several studies have documented primary pyogenic infection of the spine in intravenous drug users, and several case studies have reported spinal abscess in patients who are heroin addicts.
In this study, we examine a case of undiagnosed spinal epidural abscess that resulted in paraplegia.
CASE: Spinal Abscess Resulting in Paraplegia
A 50-year-old male presented to the ED with complaints of shortness of breath and pain in his chest and shoulder after a fall from his porch. The patient was assessed by our insured emergency medicine physician and a physician assistant (PA). Imaging studies of his humerus, chest, thorax, and cervical spine and ribs were performed and produced negative results. The patient was diagnosed with a chest contusion, given a prescription for ibuprofen, and discharged.
Three days later, the patient returned to the ED via EMS with complaints of severe sharp and constant back pain. He was seen by a second insured emergency medicine physician. The patient was assessed, and additional chest and cervical spine imaging studies were performed. No changes were noted, so the patient was given a prescription for pain medication and discharged home with a referral to see an orthopedic physician.
The plaintiff returned to the ED three days later. He shared a history of falling off his porch one week prior and reported 10/10 pain all over. He was seen again by the insured emergency medicine physician who had cared for the patient during the initial visit, as well as a PA. No neurologic deficits were noted. He denied any bladder or bowel dysfunction and had normal strength in his extremities. The physician diagnosed the patient with psychogenic back pain and discharged him with instructions for self-care for the pain.
Three days later the patient was transported via EMS to a different hospital. The patient reported complaints of numbness and tingling and an inability to bear weight while walking. He was found on the floor and was unable to move his arms or legs. The patient was ultimately diagnosed with a spinal empyema that required an emergent C5-C7 laminectomy and drainage of an epidural empyema.
The patient was hospitalized for an extended period of time and is now paraplegic. The plaintiff had a significant history of illegal drug use, and it was determined that IV drug abuse was likely the cause of the spinal abscess.
The case went to trial and returned a defense verdict, resulting in no payment by the insured. A claim for lost wages was abandoned when discovery revealed that the plaintiff had a limited work history due to extensive incarceration. The plaintiff claimed that our insured failed to do a neurological examination, which would have led to a CT scan that could identify a spinal abscess. It is documented, however, that the PA performed a physical exam and there were no neurological findings. Our emergency medicine experts shared that it is standard practice in the emergency room for a doctor to rely upon a PA to perform physical exams.
Risk Management Takeaways:
- If a patient has a known history of IV drug use and presents to the ED multiple times with the same complaint, physicians should have a higher level of suspicion to rule out additional diagnoses, such as spinal abscess.
- Physicians should provide patients with discharge instructions and discuss details directly with them directly, specifically outlining what symptoms require immediate attention.
- Practice leaders should develop processes to make follow-up calls to patients following discharge as a way to evaluate ongoing conditions and provide recommendations on when to return to the ED with ongoing or worsening symptoms.