Deceased became a paraplegic in 2015 at the age of 73 and passed away June 12, 2021. Prior to the issue at hand, the deceased had been experiencing chronic back pain and was in need of dual knee replacement.
Issue: Possible failure to treat an infection in the dura and failure to timely release compression on the spine due to fluid build up post spinal epidural.
J.P. was a 73 yo man with a hx of chronic low back pain due to degenerative disc disease at L4-S1. He had received multiple epidurals, with at least 3 in November & Dec. 2014 and January 2015. In March 2015, an MRI revealed an “extruded disc at L4. He was also being worked up for b/l knee pain, and had decided to have total knee replacement – starting with the right knee, scheduled for July 2015. On 5/5/15, he reported he’d traveled to the DR, where he may have had an epidural done, on the flight home, his pain worsened. He had a LS x-ray done in case he would alter need back surgery.
On 6/24/15, he presented to the ED not being able to walk with pain at 10/10. He reported having an epidural injection on 6/22/15. The back examination appears to have been cursory – it includes a notation that he had + SLR (pain at the back with straight leg raising) relative to the R leg. This exam does not mention any other aspects of an examination that would be expected for someone presenting with his complaints, such as DTRs, sensory exam, palpation of the spine, etc. He did not have an elevated temperature. No LS spine X-rays were done, no lab work was done. He was given Percocet. A little later the Dr. noted he was sitting up, said he felt improved and was ready to ambulate, and he was discharged. No mention as to whether he was actually observed ambulating. Was it a departure from the standard of care not to perform an LS spine x-ray on 6/24/15 since his pain was so bad he wasn’t able to walk, and he’d recently had an epidural injection on 6/22?
On 6/27/15, he returned to the ED. We don’t know what time since we don’t have the ED records for this visit, we do have the lab reports, however, that indicate blood collected at 13:37.
Neurosurgery was consulted at about 6 am on 6/28/15 – with notations at that time indicating an MRI revealed “diffuse posterior epidural collection concerning for hematoma resulting in canal compression.” He was on antibiotics out of apparent concern that he may have a UTI. ‘
On 6/28/15, at 12:30 pm, the attending radiologist noted his findings on the MRI that now included not only a posterior abscess, but also an anterior abscess and severe canal stenosis – from both the abscess and the prior degenerative changes – he also notes he discussed these findings with a doctor (not sure if a NS resident), at 12:30 pm.
On 6/28/15, at 14:36, NS PGY 3, noted the MRI now showed fluid collection concerning for abscess with compression of the spinal cord, he was ill appearing, writhing in bed, moaning unintelligibly, blood culture results revealed bacteremia/blood cultures positive for MSSA (methicillin susceptible staphylococcus aureus), she was unable to elicit DTRs at the lower extremities, he had developed progressive altered mental status – not clear if from Ativan/Morphine or meningitis. The plan was to admit to the neuroICU.
SHOULD THE PLAN HAVE INCLUDED SURGERY TO EVACUATE THE ABSCESS? It appears all the information necessary to make a decision to take this patient to surgery was present and known as of 12:30 pm, certainly by 14:36 on 6/28/15, was it a departure not to do it then to avoid further injury?!
ON 6/29/15, at 5:00 it’s noted he no longer had any movement at his lower extremities, at 6:43 am he had to be intubated due to respiratory distress due to fluid overload and chest congestion.
He was finally taken to the OR sometime after 8:07 am on 6/29/15, where it’s noted “abscess fluid and purulent material found, etc.
A subsequent note by a Neuro attending states “MSSA bacteremia likely 2/2 steroid injection. This MD also notes organ failure of at least one organ requiring constant medical attention (not sure which one, but his Troponin levels were elevated, his BUN/Cr were elevated and he had an MRI positive for pus – as late as 8/25/15 – so it’s likely he had multi-organ failure due to the severe septic shock). As per his family, he also became paraplegic.
Was there was likely a deviation from the standard of care in failing to timely evacuate Mr. Peralta’s abscess given the results of the MRI as documented.
What about causation? We are unsure whether it was the compression on the spine which caused Mr. Peralta’s injury or was it the severe infection within the dura was the cause of the parapelagia.
Is it possible that the puncturing of the Dura (from the epidural 6/22) allowed bacteria to flood the CSF and an infection to develop causing microvascular changes and ischemia due to inflammation in the cauda equina. Typically, the compression by the abscess on the spine would cause the deterioration and erosion of the nerve rootlets through ischemia.
In that Mr. JP was not febrile and did not have a white count when he first presented on 6/27, will we may have a difficult time proving they failed to given abx sooner? (They did give Zosyn on 6/27 it appears).
If the nerve damage was caused by the infection is it true that an earlier decompression would not have changed the result?
Was the failure to properly work Mr. JP up when he presented to the ED three days earlier on 6/24 and limited workup the true cause of his eventual paralysis?
Had they performed an MRI on 6/24, they would have seen the abscess and some fluid collection (per Arle, based on the MRI report, that amount of fluid would not build up overnight and would be seen on 6/24), performed a spinal tap, given abx much sooner, and stemmed the sepsis
please see the attached memo further consideration.
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No questions yet!
Do you believe there might have been medical error?
Failure to identify sepsis and treat it with the proper dose of ABS Failure to perform source control
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Acute myelopathy, spinal cord compression from an abscess, sepsis,s eptic shock
What makes you a good expert for this case?
Neurocritical care Critical care medicine
How often do you encounter cases similar to this one in your practice?
Daily basis Re: IVDA, chronic back pain, elderly with invasive steroid, analgesic injections in outpatient setting HIV, immunosuppressed chronic cancer patients, etc.
Do you believe there might have been medical error?
He needed to be decompressed earlier
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Zosyn has poor coverage of the cns especially if there was cns instrumentation. He needed more broad spectrum antibiotics
What makes you a good expert for this case?
I treat similar cases routinely from a Neurocritical Care perspective. I would have pushed to have this patient evacuated earlier. I feel it may have changed the outcome
How often do you encounter cases similar to this one in your practice?
I encoynter simikar cases atleast 1-2 times a month
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Comments are accepted only from Neurocritical Care (Any Specialty) experts.