Spinal Epidural Abscess: Let’s find a way to stop this nonsense

By Charles A. Pilcher MD FACEP
April, 2016

Too many spinal epidural abscesses (SEA) are being missed. Too many patients are left paralyzed. Too little is being done to prevent these tragedies.

It’s time for the medical and legal professions to figure out how to work together to prevent these tragedies. Suing doctors, then burying the results in non-disclosure clauses, is not working.

I have waited to publish this “Perspective” on SEA’s for over 3 years but have not done so because I have been involved as an expert in one  case or another throughout that time. Since the epidemic does not appear to be slowing, I can no longer wait. Patients continue to be unnecessarily harmed. By expressing my views now, perhaps I can encourage our two professions to find a way to work together to improve patient safety. Attorneys reading this (whether defense or plaintiff), physicians and malpractice insurers, can do more than continue to close the barn door after the horse is out.

Disability from an SEA is preventable. Let’s find a way to stop this horrible epidemic of nonsense.

I got involved as an expert on my first SEA case nearly 5 years ago. I had been working on the case for only a month when I was contacted about a second case. Since then I have been personally involved in at least 8 such cases and aware of at least 4 more. The diagnosis is not that difficult to make, so it’s tragic that physicians are still missing the diagnosis, leading to serious patient disability, paraplegia, quadriplegia and even death.

Lawsuits are doing nothing to teach doctors how not to make the same preventable mistakes as a colleague. The results of settlements are confidential, doctors and hospitals are rightfully embarrassed to share these outcomes and most shockingly, insurers rarely do anything helpful to keep their insureds from repeating the mistakes. As a result, we have paid nearly $50 million in SEA settlements in Washington State alone in just the past 5 years.

That’s ridiculous and shameful.

The sad fact is that each of the injured patients probably believes that they are the only person to whom this has ever happened. Little do they know that suing a doctor for a missed diagnosis does almost nothing to “keep this from happening to someone else.”

Two years ago, realizing that the legal and insurance professions were doing nothing to educate physicians about these tragic misses, I began publishing a newsletter (similar to this one) for my physician colleagues. It’s called Medical Malpractice Insights – Learning from Lawsuits. Among dozens of other topics, I have reported on the outcomes of at least 4 SEA cases with which I am familiar. Over 500 physicians read MMI each month, and to my knowledge there has not been a single missed SEA in any of the readers’ hospitals in the 2 years since the publication was started. I wish the same could be said for n0n-readers. By writing MMI and sharing the experience of closed cases (and yes, some of the cases are defensible), patients can be given a voice so that their suffering might indeed prevent another person from becoming paralyzed.

At the root of the problem for attorneys right now is their/your unwillingness to take any of these cases to trial, where a public verdict gives the injured plaintiff an opportunity to be heard. Burying these cases with confidential settlements and non-disclosure clauses is literally causing patients to be buried. Please help do what you can to stop this – even if it means taking more cases to public trial.

SEA is not rare. In our hospital alone (55,000 ED visits per year), we seen an several cases a year, and we have yet had a single patient leave the hospital disabled. Early recognition, early treatment and early surgery (not always needed if caught soon enough) are the key. The critical step is that doctors must think about it in every back pain patient.

Most of the time, the diagnosis can be eliminated on history alone. If not, a sed rate or CRP test is usually diagnostic, the result being “shockingly elevated” according to one consulting neurosurgeon and my own experience.

Once one thinks about it, here’s some features of SEA that help one determine next steps:

  • Relatively gradual onset of back or neck pain, usually unrelated to a specific incident.
  • Constitutional symptoms, like just not feeling well.
  • Usually NOT in a classic drug seeker type back pain patient. Patients may in fact be stoic but concerned. They seem to know that something out of the ordinary is happening – and that applies to the drug-seekers as well.
  • There is often some sort of neurological complaint, ranging from tingling or numbness in the leg or arm to classic cauda equina syndrome with urinary retention (and don’t blame that on narcotic use)
  • Patients with any gait abnormality are high risk.
  • Hardware or prior spine surgery is a red flag.
  • Other risk factors include recent surgery, dental work, IV drug use, immuno-compromise and/or diabetes.
  • Fever
  • Slightly elevated WBC
  • Elevated sed rate or CRP, usually markedly elevated. (And if normal, it’s a huge defense proving that SEA was thought of and ruled out.)
  • Repeat ED or unscheduled office visits, sometimes 3 in a week or less, sometimes several over a few months.
  • Abnormal spinal fluid, which may or may not grow an organism. (An LP is generally contra-indicated, but sometimes done if another diagnosis is top of mind.)
  • Positive blood culture. (If all else is normal, and a physician does a “just in case” blood culture, a broad spectrum antibiotic should be prescribed until the culture results are available.)
  • If suspicion is moderate to high, an MRI of the entire spine is needed. A neck abscess can cause leg symptoms.

So let’s do what we can, work together and stop this epidemic.

If this continues, I’m considering inviting a dozen or so SEA victims to dinner (at a restaurant with good handicapped access) and begin the evening by asking the group “How many of you have had a spinal epidural abscess?” And then ask “How many of you thought you were the only one?”

The conversation thereafter should be interesting.

 

{ 1 comment… read it below or add one }

Martha Deed May 7, 2016 at 4:15 PM

Thank you for bringing attention to this very important issue. My daughter died of a spinal epidural abscess that was diagnosed by autopsy.

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