A 72 year-old man presented to the emergency room on 3-12/13-17 with back pain.
He had prior history of back surgery. The ED decided to transfer the patient back to the hospital where he previously had back surgery,
There is a note by ER physician at transferring hospital that the patient stated "back is killing me. WBC 22.5 and Hb 14.3,” Workup at Hospital included CT A/P showing posterior fusion of L2-L5 and advanced degenerative arthritis. Hospital noted that "At 0300 on March 13, 2017, 2 positive blood cultures returned for gram positive cocci in pairs and clusters. The primary hospital was contacted and notified of those results.
On admission to the primary hospital (medicine floor) on 3-12/13- 2017, concern arose for osteomyelitis of the spine given leukocytosis, elevated ESR/CRP, and pain out of proportion to ordinary chronic pain.
On 3-13-17 at 07:16 AM, the patient was identified as a "fall risk" by nursing.
On 3-13-17 at 11:20 AM, the Nursing Inpatient Note identified "back pain, generalized weakness"
On 3-13-17 at 12:16 PM, nurse noted "left leg numbness/tingling and severe weakness to bilateral lower extremity".
On 3-13-17 at about 3:15 PM patient was diagnosed with Staph Aureus Epidural/paraspinal abscess with T12 osteomyelitis. Reflected in the Neurosurgery Note is documentation of MRI obtained around 4 PM that lab work is suspicious for infectious process (ESR 6, CRP 27.4 and GPC in blood).
On 3-13-17 before fall, patient was "documented by nursing at 70=high risk for falling. Patient at high risk for fall. Patient has pain in legs."
On 3/13/2017 at 4:00 PM an MRI lumbar spine was performed and indicated the following: prior L2-L5 instrumented fusion. There are adjacent segment changes resulting in severe canal stenosis at L1-L2. There are also degenerative changes causing severe canal stenosis at T12-L1. Additionally, there appears to be a suspicious fluid collection in the right paraspinal musculature at T12 that extends through the foramen as an epidural abscess at T12, causing compression of the spinal cord at this level.
On 3-13-17 about 6:28 PM (before falling), MD was informed of critical value result of gram stain/aerobic bottle positive and coagulase staph positive.
On 3-13-17 at 6:30 PM, nurse identified patient as "fall risk".
On 3-13-17 at 7:31 PM, nurse identified Mr. patient as "fall risk".
On 3-13-17 at 8:25 PM, patient fell in the bathroom alone, and called for help.
Since fall, he has complained of numbness from just beneath his belly button and not being able to move his legs. He also had burning shooting pain down his legs and his groin, although this has somewhat subsided. Given his imaging findings and acute neurological deficit, Neurosurgery was consulted.
The MRI done at about 3:15PM was reviewed after the patient fell. The MRI report states “MRI reviewed after patient fall" and described paraspinal abscess from T12-L1 causing compression of spinal cords.
There is a note that radiology spoke to internal medicine resident around 8:30 PM "Fall in setting of known degenerative disease and large paraspinal abscess. Patient with large abscess on MRI and evidence of bacteremia as blood culture have grown gram positive cocci in clusters.”
On 3-14--17, Neurosurgery noted "MRI lumbar spine imaging which showed abscess in the paraspinal musculature extending into the epidural space." NSGY impressions was that patient "likely suffered acute spinal cord injury at the time of his fall, on top of his cauda equina compression from his adjacent segment disease."
He was taken to the OR emergently for T12-L2 decompression and epidural abscess washout on 3/14/17. Post operatively patient is showing some spontaneous neurological recovery but is limited in participation with PT by pain.
On 3-15-17, Neurosurgery, reports that patient has Staph Aureus Epidural/paraspinal abscess and T12 osteomyelitis from Staph Aureus..."This is a severe infection and the resultant poor outcome is the result of a prolonged untreated infection."
PT manual muscle testing on 3/16/17 shows: "Pt able to demonstrate ankle AROM and contractions in more muscle groups today. strength: hips bilat grossly 2-/5, quads 1 to 2-/5, R hamstring 1/5, L hamstring 0/5".
RECOMMENDATIONS: Current estimated level of injury is ~T12, Incomplete Motor Non-Functional. Patient meets criteria for SCI Program and will be referred to Augusta SCI Center (This recommendation was added after the fall though MRI had been taken 5 hours prior)
Was there a delay in diagnosis and treatment of an epidural abscess?
If that is the case, did the delay in treatment likely contribute to the poor outcomes?
Is it likely that the fall exacerbated the spinal compression?
Files:
No questions yet!
Do you believe there might have been medical error?
As long as the PT was intact neurosurgeon could have intervened at the point of which pt just had numbness but remained neurologically intact
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Results of wbc, And PT s. numbness are suggestive of spine infection. Longer you wait to communicate that clinical info to neurosurgeon, the less likely pt will have good outcome from surgery.
What makes you a good expert for this case?
Testifying on one in Texas soon
How often do you encounter cases similar to this one in your practice?
I have encountered cases similar to this one a few times
Do you believe there might have been medical error?
The case summary timing is a bit confusing. It says the MRI was done at 4:00 PM on the 13th with the result as mentioned above. A few lines later, it says the MRI was done about 3:15 PM and reviewed after patient's fall. So, I'm not sure if the MRI result was present (radiologist read the MRI before the fall or not). However, my overall thought is that this patient has already presented with an abnormal CT scan, numbness and tingling and positive blood culture.. This is enough evidence to first start the patient on empiric antibiotic and obtain STAT MRI of the spine to r/o spinal cord injury/involvement, which according to the summary it looks like that was done appropriately (but I'm not sure about the timing as I mentioned above). However, in case of suspicion of spinal cord injury, the patient should've been 1) admitted to ICU, 2) was kept in complete bed rest (no ambulation at all). It looks like the level of care for this patient was not appropriate and the patient was not bedrest (unless the patient decided to get out of bed against medical advice). Therefore, admitting the patient to the medical unit and allowing him to use the bathroom was a clear medical error that led to the fall and caused the injury.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It looks like the patient was able to ambulate prior to the fall and the only neurological symptoms was numbness, tingling, and pain. Although it is difficult to say for sure that the fall was the cause of worsening lower extremity weakness, the document immediate worsening in symptoms after the fall indicates that most likely the fall was the causation for the worsening symptoms. The case summary does not indicate WHEN antibiotic therapy was initiated. Empiric antibiotics should've been started in the ED that saw the patient, prior to transferring the patient and then resumed upon arrival. The NSG statement "prolonged untreated infection" may be an indication that antibiotic was never started until NSG was consulted. If that's the case, then delay in antibiotic is a significant medical error and cause for the injury.
What makes you a good expert for this case?
I'm a board-certified Internal medicine and Critical care medicine with over 8 years of experience in managing all types of critical care illnesses. Spinal cord abscess/injury is a critical diagnosis that always requires the care from the critical care team and I have managed many patients with this condition in the past several years.
How often do you encounter cases similar to this one in your practice?
As an intensivist, I receive multiple consults for a possible spinal injury and manage over 10 cases of spinal abscess/injury per year.
Do you believe there might have been medical error?
In a setting of documented weakness, bacteremia, elevated WBC and inflammatory markers, and MRI evidence of epidural abscess with spinal cord compression, the neurosurgeon should be consulted immediately. This constitutes a neurosurgical emergency for decompression to minimize risk of neurological injury.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The data suggests that there was delay from the time the MRI was completed until Neurosurgery saw the patient. There was Also a delay from the time the patient fell on 3/13 and the time he was decompressed on 3/14. The delay period is not specified but it is suggested to be at least 4 hours.
What makes you a good expert for this case?
I specialize in complex spine surgery.
How often do you encounter cases similar to this one in your practice?
Our group encounters these cases every 1-2 weeks.
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