Portal de Periódicos da CAPES

SEA Often Missed, but Making the Correct Diagnosis Is Easy

2023; Lippincott Williams & Wilkins; Volume: 45; Issue: 8A Linguagem: Inglês

10.1097/01.eem.0000966980.00856.ba

1552-3624

Charles A. Pilcher,

Spinal Dysraphism and Malformations

FigureFigureThe classic triad of symptoms occurs in less than 15% of patients A 58-year-old woman with diabetes presented to the ED with acute, new-onset back pain. She was diagnosed with nontraumatic back pain and discharged with symptomatic care. She returned 10 days later with continued back pain and an altered mental state. She was admitted with a diagnosis of sepsis, but the source was not identified for five days when an MRI of her spine revealed a low thoracic spinal epidural abscess (SEA). Decompressive surgery was done immediately, but she was a paraplegic when discharged a month later. A lawsuit was filed against her infectious disease physician and the hospital. Both EPs were employees of the hospital, but only the second one was a defendant. The Plaintiff's Case The patient's attorney said her diabetes and unexplained back pain were conditions for which a cause should have been sought. He said the physician should have thought of SEA and done an MRI when she was admitted before she became paralyzed because the source of her back pain and sepsis likely would have been found. The Defense's Case The attorney for the defendants said the patient had an SEA, but that wasn't what paralyzed her. Her spinal cord was not compressed, and instead she had suffered an infarct due to the abscess, which would not get better when the abscess was removed. The attorney said the patient arrived at the hospital with life-threatening sepsis, kidney failure, and diabetic ketoacidosis, noting that multiple physicians and consultants treated her appropriately for the infection, her care was excellent, and her paralysis was the result of the devastating effects of the infection, not a delay in diagnosis of the SEA. The Verdict An $18 million jury verdict was returned against the attending ID physician after a seven-day trial and less than five hours of deliberation. The hospital and its EPs were found to be 10 percent liable, but they had been dismissed from the case before the trial. Takeaways SEAs can damage the spinal cord by directly compressing the cord by the abscess or from pressure on the spinal arteries serving the spinal cord. The latter is much less frequent, but the assessment of the problem is the same. Diabetes is a major risk factor for SEA, as are alcohol use disorder, having spinal hardware, and immunocompromise. Opioid misuse is also a risk factor. Repeated visits, even by suspected drug users, must be carefully evaluated. Note that the original emergency physician was not named in the suit. The first doctor to see a back pain patient with an SEA is almost always given a pass if no neurologic symptoms are present. The classic triad for SEAs (pain, fever, neurologic symptoms) is present in less than 15 percent of patients, and those patients are almost always left with permanent injury. Think of SEA in all patients with back pain, especially those with risk factors. A CRP or ESR will be elevated in about 99 percent of cases. Order one if SEA is even remotely possible. Doing the test indicates you thought of it and supports the decision not to do an MRI. Include that in the medical decision-making portion of the medical record. An MRI is the standard of care if SEA is highly suspected. Always look for primary sources of sepsis. A spinal epidural abscess can cause sepsis, and sepsis can cause a spinal epidural abscess. Common primary sources of SEA are UTI, dental abscess, and skin infections, among many others. This case is a reminder of how frequently SEAs are missed and how easy it is to make the correct diagnosis. The key is to think about it whenever seeing a patient with back or neck pain, especially when a patient bounces back. References Spinal Epidural Abscess. Medscape eMedicine. May 31, 2022; https://bit.ly/3Osc1ha. Additional SEA cases reviewed on Medical Malpractice Insights. July 2016; https://bit.ly/3rISxMt. DR. PILCHER is a retired emergency physician and the former medical director of the ED at EvergreenHealth and Evergreen Medic One in Kirkland, WA. He has reviewed hundreds of medical malpractice cases for plaintiff and defense attorneys throughout his career, and is also the editor of Medical Malpractice Insights-Learning from Lawsuits (https://bit.ly/MedMalInsights), a monthly newsletter focused primarily on diagnostic errors in the ED. Send stories you would like him to review to [email protected]. Read his past columns at https://bit.ly/PilcherMedMal. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].