Missed spinal epidural abscess: Why can’t we stop this?

Perspective: Missed spinal epidural abscess
Are attorneys and insurers as responsible as doctors for this epidemic?
By Charles A. Pilcher MD FACEP
January, 2016

I am shocked, embarrassed, disappointed, concerned and yes, angry. Last month I learned of a seventh patient paralyzed because a spinal epidural abscess (SEA) was diagnosed too late. And that’s only in the past 4 years – and only cases of which I am personally aware. Five of these 7 have been in Washington State. What must be happening in the rest of the medical-legal universe?

All but one have been egregious. All have had one or more major risk factors. All have had one or more classic signs and/or symptoms. Most of the time the patient’s history alone is enough to make the diagnosis. The problem in each case has been that the history is either not adequately taken or is discounted because of the patient’s demeanor or prior record. Emergency physicians have missed the diagnosis. Hospitalists have missed the diagnosis. Even neurologists have missed the diagnosis.

Has missing this diagnosis become the new standard of care? How many patients must become paraplegics or quads before we stop this? Why are presumably competent physicians unable to make this diagnosis while there is still time?

It’s pathetic.

Diagnosing SEA

Why is it pathetic? Because the diagnosis of SEA is not difficult to make – if one thinks about it. And a physician should think about it when the patient:

• has multiple visits in a short time frame for increasing spinal symptoms
  pain is out of proportion to any known injury
• is in emotional as well as physical distress about the increasing (as opposed to persistent) pain
  complains of weakness or numbness in the legs, even if one believes the patient to be malingering
• has increasing difficulty walking
• complains of associated fatigue, malaise, weakness
• has a history of drug or alcohol use, especially IVDA, either current or remote
• is diabetic
• is immunocompromised due to HIV, chemotherapy, steroids, etc.
• has a fever
• has had prior spinal surgery, especially with implanted hardware
• has trouble urinating, especially with urinary retention
• is constipated

Fortunately SEA progresses in a relatively linear pattern. Fortunately the progression takes a few days to weeks (usually longer than cauda equina syndrome, a similar condition due to disk impingement rather than a growing infectious mass.) Fortunately, a simple screening test can rule out the diagnosis and demonstrate that one was at least thinking of SEA. And fortunately, until nearly all of the above symptoms, physical findings and lab results are present, intervention can prevent complete paralysis.

As a community hospital neurosurgeon explained, “The sed rate (ESR) [CRP can also be used /cp] is a simple test and screamingly high nearly 100% of the time. This may be a simple and cheap way to screen the legions of patients with lower back pain, with few false positives… We see SEA at least once a month, but thanks to great emergency care have never to my knowledge missed one. If antibiotics are started early, surgery is usually not necessary.”

But SEA can be a sneaky disease. It sometimes causes symptoms and signs some distance from the location of the abscess. Thus, once a physician thinks about it, one must image the entire spinal column, not just the part that hurts. A negative lumbar MRI has lulled many physicians into missing the diagnosis in a patient with low back pain. The abscess may be only 1-2 levels higher, or it may be all the way up in the neck. While MRI is preferred, SEA’s may be found (much less reliably) with contrast CT – or even plain CT.

What’s going on?

So, if the diagnosis can be easily made before paralysis is irreversible, why are so many being missed? Yes, one’s training may have been incomplete. Yes, one’s experience may be limited. Yes, the patient may have had back pain before. However, the common theme is always that the level of suspicion is inadequate. SEA is not being considered. So what must we do?

Clearly, suing doctors after the horse has left the barn is not working. As I said above, all but one of the 7 cases of which I am aware has been egregious, so egregious that of the 6 lawsuits filed, none went to trial. All 6 were settled – for millions of dollars each.

But each was settled confidentially. And there’s the rub.

Confidentiality clauses and non-disclosure

Case settlements (as opposed to public trials) almost always come with a “confidentiality” or “non-disclosure” clause. Those clauses are perceived (rightly or wrongly) as a “gag order” against discussing anything about the case, so the outcome of the case is never discussed in physician circles. The attorneys can’t tell anyone, and the hospital and defendant doctors don’t want to tell anyone. The insurance company may publish a pedantic treatise for their insureds which few read. They might include a brief case example in a newsletter, conference or webinar to which few physicians pay attention. So because of confidentiality, no one feels free to simply explain to other doctors “A mistake was made.” “Here’s how it was made.” Here’s what happened to an unfortunate patient.” And “Here’s what you can do – must do – to never make the same mistake yourself.”

“So what? I’m here to do my job, to work for my client, not change the world,” an attorney has said.  The patient and/or family got compensated, the attorneys got paid, the insurance company did their best to limit the damages, and hopefully the defendants learned something. But what about other doctors? What about the ones who didn’t learn from a colleague’s experience and made the same mistake as their colleague? How would you as an attorney or an insurance company executive feel if you or a family member were patient #2, or #3 – or worse yet, #7. Angry? You bet!

And I’m angry, knowing that multiple patients are now paralyzed because confidential settlements keep physicians from learning anything from the experience of others. Attorneys and insurers need to look in the mirror and ask “How could I have helped another doctor not miss this diagnosis? How could I have helped keep the next patient from becoming paralyzed? Do I really have a responsibility only to my client? Is there not a greater good? Do I not have a responsibility to patient safety? To society?”

What can we do?

This epidemic of missing the diagnosis of SEA is unacceptable and unnecessary. Physicians must learn from these lawsuits, and non- disclosure of earlier case settlements has kept that from happening. In the case of SEA, non-disclosure has caused subsequent patients to be unnecessarily paralyzed.  We all owe it to our patients and clients to find way to prevent this. If we physicians are making mistakes, we must know what those mistakes are. Acknowledging that confidentiality / non-disclosure clauses are a significant part of the problem, then eliminating or modifying them, must be part of the solution. 

Suing doctors and burying the outcome is doing nothing to improve patient safety. Allowing the same mistake to be made over and over again is insane and devalues the injured patients, most of whom have filed lawsuits in part “so that this won’t happen to anyone else.”

If only they knew.

[Editor’s Note: Since writing the first draft of this “Perspective,” I have become aware of an 8th case (6th in Washington State) of paralysis due to a missed SEA. That’s a crying shame. / cp]