Missed Spinal Epidural Abscess: ‘Lightning Rod for Litigation’
Missed or delayed diagnosis of spinal epidural abscesses is a “lightning rod for litigation,” says J. Mason DePasse, MD, an orthopaedic surgery fellow at Brown University’s Warren Alpert Medical School in Providence, RI. DePasse recently analyzed 56 malpractice cases involving spinal epidural abscesses.1
“Epidural abscesses are a challenge. The symptoms are often nonspecific; as any emergency physician can tell you, countless people present with back pain,” he says.
Unfortunately, this condition can be as devastating as it is difficult to diagnose. Patients may be left paralyzed or with a range of neuropathic symptoms, including weakness and pain, that never go away. “Frustrated patients wonder if something could have been done sooner,” DePasse says.
Investigators searched the literature for research on lawsuits associated with epidural abscesses. They found only one small study with limited data for analysis. “We were surprised to find that there was very little information available. So we decided to perform our own study,” DePasse says. Some key findings:
- Of the 56 cases, 17 were settled, 22 resulted in a defendant ruling, and 17 resulted in a plaintiff ruling. Internists were the most commonly sued physicians (named in 13 suits), followed by EPs (named in eight lawsuits).
- The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic, and in cases in which there was delay in diagnosis or treatment.
- Nonsurgeon physicians, who often are responsible for initial diagnosis, were more likely to be sued than were surgeons.
“The number one way to lose a lawsuit when treating a spinal epidural abscess is to delay treatment when the diagnosis is known,” DePasse stresses. Plaintiffs tend to prevail if they can demonstrate that the ED care resulted in a delayed diagnosis, and that a competent EP would have performed the appropriate workup.
Paralyzed plaintiffs are more likely to win malpractice suits, and also are more likely to receive bigger monetary awards. “This is likely due to sympathetic juries, which has implications for the risks of neck pain vs. lower back pain,” DePasse says.
The patient’s age and sex were not relevant. “Interestingly, whether the patient had a known infection prior to diagnosis did not matter either, despite that one might argue the physician should have had a higher suspicion for a new site of infection,” DePasse notes.
For EPs who want to reduce legal risks, the study highlighted two important things: the need for increased awareness of epidural abscess, and the need for timely diagnosis and treatment.
“Regardless of all other factors, the key in these lawsuits is whether the plaintiff can show that a ‘competent physician’ would have made the diagnosis faster,” DePasse says. He recommends EPs consider these practices to avoid missed or delayed diagnosis of epidural abscesses:
- Keep in mind that only a small percentage of patients present with “classic” symptoms.
Did a patient present with the classic triad of fever, back pain, and neurologic deficits? The EP will be expected to make the diagnosis promptly with imaging and laboratory workup. However, few patients present this way. On the other hand, DePasse says, “almost all patients show up with a chief complaint of neck or back pain.”
Concerning additional historical factors include: the remaining “triad” symptoms, history of intravenous drug abuse, history of diabetes, history of kidney disease, and recent infection at a remote site. Of particular concern? A known methicillin-resistant Staphylococcus aureus infection.
- Maintain a high index of suspicion for patients with repeat ED visits for back pain.
Many patients with abscesses present two or more times to EDs with the same complaints.2 “For patients who present with nonspecific lower back pain and no other symptoms, defendants can argue that no competent EP would have suspected epidural abscess on the first ED visit,” DePasse says. This may be a more difficult argument to make if the patient returned to the ED, and the diagnosis wasn’t made during that ED visit either. “Documenting the presence of spine tenderness and a thorough neurologic exam for these patients is essential,” DePasse counsels.
- If there is suspicion, appropriate laboratory workup should include blood cultures, white count, erythrocyte sedimentation rate (ESR), and C-reactive protein.
“Studies have shown that ESR is the most sensitive and specific marker for epidural abscess, and it is not very specific,” DePasse notes.3
- If any concern remains, order an MRI with gadolinium of the entire spinal axis.
“An MRI of the area of complaint is not enough,” DePasse warns. “Patients may have contiguous infection in different areas of the spine, and there were cases of catching one abscess and missing the other.”
- If imaging reveals an abscess or a question of an abscess, seek urgent spine surgical consultation, or rapidly transfer the patient to a facility with spine surgery available.
“All cases in which this was delayed resulted in plaintiff verdicts,” DePasse notes.
- DePasse JM, Ruttiman R, Eltorai AEM, et al. Assessment of malpractice claims due to spinal epidural abscess. J Neurosurg Spine 2017;12:1-8.
- Davis DP, Wold RM, Patel RJ, et al. The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 2004;26:285-291.
- Davis DP, Salazar A, Chan TC, Vilke GM. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain. J Neurosurg Spine 2011;14:765-770.
- J. Mason DePasse, MD, Orthopaedic Surgery Fellow, Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI. Email: [email protected].
In these cases, EPs are the second most commonly sued physicians.
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