Medical Review

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Case 1: Shortness of Breath

Case 2
Post 1: Introduction Pt 1
Post 2: Introduction Pt 2
Post 3: Introduction Pt 3
Post 4: Bad Outcome Pt 1
Post 5: Bad Outcome Pt 2
Post 6: Legal Outcome
Post 7: Documentation Review
Post 8: Medical Review

This case is every EM doctor’s worst nightmare. The presentation is very subtle and the patient has no obvious signs of underlying emergency until very late in the disease process. The outcome is tragic for the patient and his family. Spinal epidural abscess (SEA), while relatively rare, is one of the diseases with extremely high malpractice pay outs (https://www.ncbi.nlm.nih.gov/pubmed/28498071). Patients suffer a lifetime of disability that need to be covered with very high costs.

• SEA is easy to miss.

One of the most challenging aspects of diagnosing spinal epidural abscess is the subtlety of the presenting complaint. There is significant overlap between early SEA and many nonspecific viral syndromes. Fever, back pain, headache, general discomfort are all common in both disease processes. It is a very rare diagnosis, found in <1.2 cases per 10,000 hospital admissions. Some ED physicians may go an entire career without ever diagnosing SEA. The classic triad includes fever, back pain and neurologic deficits but the triad is rarely present until very late, if at all. http://www.emdocs.net/spinal-epidural-abscess/

• If you’re going to test for SEA, it has to be with an MRI.

Ordering a CT scan is probably not going to help you. Back xrays are useless. Doing an LP will not get you the diagnosis. There’s only one test you need, and its an MRI of the spine. There’s really no short cuts here. MRI is the gold standard. https://lifeinthefastlane.com/ccc/spinal-epidural-abscess/

• If you’re going to get an MRI, scan the entire spine.

This is a classic mistake. A doctor is worried about SEA and actually orders the right test, an MRI! Great! But then, for whatever reason, they order an MRI of only one part of the spine. They make a huge gamble and put their entire bet on either cervical, thoracic, or lumbar spine. Sometimes the doctor is right and doesn’t realize how luck their guess was, sometimes they’re not lucky. Don’t leave your patient’s care up to luck. In this case, the ER doctor gambled and lost. They got an MRI and didn’t find the abscess because they guessed wrong. Fortunately their astute colleagues in the hospital completed the MRI to find the abscess.

There are two common reasons to only order an MRI of one part of the spine. The first is to save time. If you’re worried enough about SEA to order an MRI, just bite the bullet, order the entire spine, and take the hit to your efficiency. You’d rather be right than fast in this case. The second reason is because radiology pressures you into only ordering one section. Don’t let them pressure you; you’re the one who has actually seen the patient, you’re the one who will take the fall if you miss this. In some ERs ordering an MRI of the spine is nearly impossible and in some ERs you can get it done as easily as a urinalysis. Do the right thing, order the MRI of the entire spine if you’re worried about an SEA (or transfer them to a hospital that will do it).