Medicolegal Cases for Spinal Epidural Hematoma and Spinal Epidural Abscess

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1 n Review Article Instructions 1. Review the stated learning objectives at the beginning of the CME article and determine if these objectives match your individual learning needs. 2. Read the article carefully. o not neglect the tables and other illustrative materials, as they have been selected to enhance your knowledge and understanding. 3. The following quiz questions have been designed to provide a useful link between the CME article in the issue and your everyday practice. Read each question, choose the correct answer, and record your answer on the CME Registration Form at the end of the quiz. 4. Type or print your full name and address and your date of birth in the space provided on the CME Registration Form. 5. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity. 6. 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After that date, the quiz will close. CME Registration Forms received after the date listed will not be processed. CME ACCREITATION This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Vindico Medical Education and Orthopedics. Vindico Medical Education is accredited by the ACCME to provide continuing medical education for physicians. Vindico Medical Education designates this Journal-based CME activity for a maximum of 1 AMA RA Category 1 Credit. hysicians should claim only the credit commensurate with the extent of their participation in the activity. This CME activity is primarily targeted to orthopedic surgeons, hand surgeons, head and neck surgeons, trauma surgeons, physical medicine specialists, and rheumatologists. There is no specific background requirement for participants taking this activity. 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Ms French and r aniels have no relevant financial relationships to disclose. r Ahn (Uri) provides consultation and expert testimony for medicolegal, workmen s compensation, and personal injury cases; provides consultation on, has grants pending on, and receives travel/accommodations/meeting expenses from Alphatec, Spine 360, and K1; and has patents for and receives royalties from spinal implant devices sold to Spine 360 and Alphatec. r Ahn (Nicholas) provides consultation and expert testimony on and is employed by worker s compensation, insurance, and legal cases; has received grants from Stryker; and has a patent pending on a spinal assessment device. r Aboulafia, CME Editor, has no relevant financial relationships to disclose. r Ambrosia, Editor-in-Chief, has no relevant financial relationships to disclose. The staff of Orthopedics have no relevant financial relationships to disclose. UNLABELE AN INVESTIGATIONAL USAGE The audience is advised that this continuing medical education activity may contain references to unlabeled uses of FA-approved products or to products not approved by the FA for use in the United States. The faculty members have been made aware of their obligation to disclose such usage. 48 Medicolegal Cases for Spinal Epidural Hematoma and Spinal Epidural Abscess Keisha L. French, BS; Eldra W. aniels, M; Uri M. Ahn, M; Nicholas U. Ahn, M educational objectives As a result of reading this article, physicians should be able to: 1. iagnose spinal epidural hematoma and spinal epidural abscess. 2. Outline the most common neurological deficits that occur from a spinal epidural hematoma or spinal epidural abscess. 3. Identify indications for a good or poor prognosis. 4. Minimize adverse outcomes for the provider. Abstract Spinal epidural hematoma and spinal epidural abscess are rare surgical emergencies resulting in significant neurologic deficits. Making the diagnosis for spinal epidural hematoma and spinal epidural abscess can be challenging; however, a delay in recognition and treatment can be devastating. The objective of this retrospective analysis study was to identify risk factors for an adverse outcome for the provider. From SUNY Upstate Medical University (KLF), Syracuse, New York; the epartment of Orthopaedic Surgery (KLF, EW, UMA, NUA), University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; the epartment of Surgery (EW), Marshall University, Huntington, West Virginia; and New Hampshire Spine Institute (UMA), Bedford, New Hampshire. The material presented in any Vindico Medical Education continuing education activity does not necessarily reflect the views and opinions of Orthopedics or Vindico Medical Education. Neither Orthopedics nor Vindico Medical Education nor the authors endorse or recommend any techniques, commercial products, or manufacturers. The authors may discuss the use of materials and/or products that have not yet been approved by the US Food and rug Administration. All readers and continuing education participants should verify all information before treating patients or using any product. The authors thank Mss Nina McLaughlin and Leslie Henry for their help with researching and acquiring the current cases, and the Timothy L. Stephens Jr, M, Fellowship rogram for developing and implementing an extraordinary curriculum. Correspondence should be addressed to: Nicholas U. Ahn, M, epartment of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Euclid Ave, Cleveland, OH (nicholas.ahn@uhhospitals.org). doi: / ORTHOEICS Healio.com/Orthopedics

2 Spinal Epidural Hematoma and Spinal Epidural Abscess French et al The LexisNexis Academic legal search database was used to identify a total of 19 cases of spinal epidural hematoma and spinal epidural abscess filed against medical providers. Outcome data on trial verdicts, age, sex, initial site of injury, time to consultation, time to appropriate imaging studies, time to surgery, and whether a rectal examination was performed or not were recorded. The results demonstrated a significant association between time to surgery more than 48 hours and an unfavorable verdict for the provider. The degree of permanent neurologic impairment did not appear to affect the verdicts. Fiftyeight percent of the cases did not present with an initial deficit, including loss of bowel or bladder control. All medical professionals must maintain a high level of suspicion and act quickly. hysicians who are able to identify early clinical features, appropriately image, and treat within a 48 hour time frame have demonstrated a more favorable medicolegal outcome compared with their counterparts in filed lawsuits for spinal epidural hematoma and spinal epidural abscess cases. Spinal epidural abscess can occur by 3 mechanisms: hematogenous spread, extension of neighboring infected structures, and iatrogenic inoculation. 1-3 Comorbidities such as diabetes mellitus, alcoholism, infection, or human immunodeficiency virus increase a patient s susceptibility to spinal epidural abscess. 4 The most common agent is Staphylococcus aureus. 4,5 Clinical features may include spinal pain, fever, and limb weakness. The pathophysiology for spinal epidural hematoma is unclear; however, it is commonly described as internal rupture of the Batson vertebral venous plexus. 6 This disease can occur spontaneously or with minor trauma, such as lumbar puncture or epidural anesthesia. Both disease processes are rare, but their incidence is increasing due to the aging population, the increase of spinal procedures performed, and the number of patients with acquired immunodeficiency syndrome. 5 In 1975, Baker et al 7 reported an annual incidence of 0.2 to 2 cases per 10,000 hospital admissions. The current annual incidence has increased to 2.5 to 3 cases per 10,000 hospital admissions. 1 elayed or misdiagnosed spinal epidural hematoma or spinal epidural abscess can lead to litigation. The Canadian Medical rotective Association reported 33 cases of spinal epidural abscess between 1996 to 2006 resulting in civil legal or regulatory action. 8 In the current study, medical negligence resulting in litigation was due to failure to diagnosis spinal epidural hematoma or spinal epidural abscess; failure to complete a thorough physical examination, including a digital rectal examination; failure to obtain appropriate imaging studies; failure or delay in consulting a specialist; and failure to maintain a sterile field. The early clinical signs and symptoms of spinal epidural hematoma or spinal epidural abscess can be associated with a broad differential; therefore, it is important to maintain a high level of suspicion. Treatment Table 1 Comparison of Cases Won by the lantiff Versus the efendant Variable laintiff (n54) efendant (n515) Sex distribution, % Male, 75; female, 25 Male, 80; female, 20 ostoperation, % No, 50; yes, 50 No, 47; yes, 53 Mean time to surgery, d Mean time to imaging, d Mean time to consultation, d Surgical specialty consulted, % Ortho, 0; NS, 50 Ortho, 33; NS, 33 Other consultation, % a Abbreviations: Ortho, orthopedic surgeon; NS, neurosurgeon. a Infectious disease, urology, pain management, and anesthesia. within a 48-hour time frame indicates a higher probability for a good prognosis but does not guarantee that permanent neurologic deficits will not occur. Medical literature in the United States has not addressed the medicolegal malpractice process involving spinal epidural hematoma or spinal epidural abscess in comparing individual factors that directly correlate with an adverse verdict for the provider. The purpose of this study was to determine whether neurologic outcomes, initial neurologic presentation, location of injury, specialty consult, time to imaging, or time to surgical intervention correlates to adverse decisions in medicolegal cases of spinal epidural hematoma or spinal epidural abscess. Materials and Methods The LexisNexis Academic legal search database was used to identify 42 state and federal cases of spinal epidural hematoma and spinal epidural abscess. LexisNexis Academic is a database that compiles primary and secondary source material in the forms of laws, statues, and law reviews. It offers information on US Supreme Court decisions from January 1790 to the present, all federal laws from 1988 to the present, and state JANUARY 2013 Volume 36 Number 1 49

3 n Review Article Table 2 Complete List of Reviewed Cases aitient Initial Sex/Age, y Initial resentation a M/# Mid-back pain, periscapular tenderness M/# Upper back and neck pain, progressed to abdominal pain and inability to urinate M/# Febrile, skin lesions on UE, shoulder and neck pain F/# Burning sensation and sharp pain in back M/# Low back pain, progressed to inability to urinate, difficulty walking M/# Weakness in legs and arms M/33 Swelling of neck with pain M/# Neck pain, chills, limited use of UE and LE M/# Numbness and weakness in LE M/# Lower back pain radiating to right buttock and thigh M/# Severe back pain and fever Time to Rectal Setting Region ostop b Surgery Consult Imaging Exam c Specialty Outcome Complaint Verdict ($) ER T No 2 d.24 h.24 h No Ortho # Failed to diagnosis, manage, and treat ER C Yes 5-6 d 5 d 5 d No Ortho Quadriplegic Suffering neurological impairment due to negligence ER T No 73 d 45 d 70 d No Rheum Neurologic deficit resulting in paraplegia ER L Yes 2 d 1 d 2 d No Ortho Cauda equina syndrome OC L No 25 h 17 h # No # Incomplete paraplegic Failed to diagnosis osteomyelitis, which caused paraplegia Failed to diagnosis and treat Failed to diagnosis and treat OC C Yes,24 h 4 d 4 d No NS # Experiencing paralysis and emotional distress; failed to diagnose and treat in timely fashion OC C Yes.30 d 30 d 30 d No NS # Failed to diagnosis and treat ER C No 20 d 4 d 19 d No I # Failed to diagnosis and treat RR C Yes,24 h,24 h,24 h No # UE weakness Failed to diagnosis OC L Yes # 10 d No No Anesth # Failed to perform a good epidural injection and maintain a sterile field ER T No.30 d 23 d 34 d No Urology ermanent paralysis from mid-waist level down M/# Back and leg pain RR L Yes 19 hr 5 hr 18 hr No NS ermanent neurological damage Failed to diagnose and treat appropriately Inadequately informed of the risks; Failed to examine and diagnose in a timely fashion; elay in imaging studies (1,044,339) (819,000) 50 ORTHOEICS Healio.com/Orthopedics

4 Spinal Epidural Hematoma and Spinal Epidural Abscess French et al Table 2 (Continued) Complete List of Reviewed Cases Time to Rectal Setting Region ostop b Surgery Consult Imaging Exam c Specialty Outcome Complaint Verdict ($) aitient Initial Sex/Age, y Initial resentation a OC C Yes,24 h,24 h,24 h No Neuro # Failed to diagnose and treat, used improper drugs M/# Chest pain and weakness in the legs ental negligence in pulling abscessed tooth F/# Left hip pain OC L Yes 11 d No 8 d No # Transferred to rehab facility Failed to diagnose and treat in timely fashion ER L No 24 h 10 h 20 h No # ermanent LE paralysis M/# iabetic ketoacidosis ER T No 9 d 9 d No No # araplegia Negligence in inserting catheter M/# ifficulty with urinating and bowel movements (125,000) ER L Yes 30 h # 29 h No NS Lumbar pain Failed to diagnose and treat appropriately F/23 Legs felt numb and heavy Failed to diagnose and treat appropriately F/49 Low back pain ER L No 60 d,24 h,24 h No ain manag Chronic low back pain Abbreviations: #, data unknown; anesth, anesthesiology; C, cervical;, defendant; ER, emergency room; Exam, examination; I, infectious disease; L, lumbar; LE, lower extremity; manag, management; NS, neurosurgeon; OC, outpatient clinic; Ortho, orthopedic surgeon;, plaintiff; ostop, postoperative; rehab, rehabilitation; Rheum, rheumatology; RR, recovery room; T, thoracic; UE, upper extremity. a Symptoms experienced at initial visit. b Neurological deficits identified for first time postoperatively. c Whether rectal examination was performed on initial presentation. court decisions at all court levels for all 50 states and territories. The following terms were searched: epidural hematoma, epidural hematomas, epidural abscess, and epidural abscesses. A total of 19 cases were identified in which lawsuits were filed against the provider for management of spinal epidural hematoma or spinal epidural abscess with dates ranging from February 1986 to November Outcome data on trial verdicts, age, sex, initial site of injury, time to consultation, time to appropriate imaging studies, time to surgery, and whether a rectal examination was performed were recorded. Although uniform in structure, each case varied in the amount of medical detail provided. Univariate logistic and linear regression analyses were performed to determine the association between adverse decisions and case data. Statistical significance was determined by a value less than.05 for each linear combination. Results Table 1 demonstrates the comparison between plaintiff verdicts and defendant verdicts in regard to spinal epidural hematoma vs spinal epidural abscess, sex and surgical specialty consultation distribution, mean age, time to surgery, time to advanced imaging, and time to consultation. Table 2 outlines the complete list of cases reviewed in the study. A total of 19 cases were reviewed and statistically analyzed. Four of the 19 cases were in favor of the plaintiff (ie, patient) with a mean award of $3.98 million (range, $125,000-$1,044,339). Linear regression analysis showed no significant correlation between loss of function and an adverse verdict for the defendant (ie, provider) (5.921). Thirteen (68%) of 19 cases demonstrated loss of function ranging from temporary to permanent. No significant difference was found in the initial presentation and an adverse verdict (5.268). Of 19 cases, 14 (74%) presented with JANUARY 2013 Volume 36 Number 1 51

5 n Review Article escalating pain, 5 (26%) with weakness, and 3 (16%) with bowel or bladder dysfunction. Spinal injury was differentiated into cervical, thoracic, and lumbar regions, with 6 (32%), 4 (21%), and 9 (47%) lesions documented, respectively. No significant relationship was found between individual spinal lesion or grouping of all cord lesions in comparison to adverse verdict (5.907 and.720, respectively). Specialists who consulted for the cases included orthopedic surgeons, neurosurgeons, and others (rheumatology, pain management, anesthesiology, urology, and infectious disease). The majority of patients presented to the emergency department (58%) or outpatient clinic (32%). No significant correlation was found between the setting of the initial presentation or specialty consultant and an adverse verdict (5.878 and.568, respectively). The only statistically significant risk factor influencing litigation decisions was a time to surgery greater than 48 hours (5.013). The 4 cases in favor of the plaintiff had an average of 33.5 days to surgery (range, 30 hours to 73 days). However, 6 cases found in favor of the defendant had an average of 18.9 days to surgery (range, 6 to 60 days). Of these 6 cases, 3 were won by the defendant due to statute of limitations and 3 sided with the defendant for lack of evidence or inappropriate documentation. iscussion Spinal epidural hematoma and spinal epidural abscess are medical emergencies that require prompt diagnosis, appropriate imaging, and referral to qualified spinal surgeon for further assessment. As reported in this study, the time frame for action is restricted to 48 hours. hysicians should not rely on neurological deficits seen on initial presentation to solidify a diagnosis of spinal epidural hematoma or spinal epidural abscess. Only 42% of the cases reviewed presented with neurological impairments, but 74% of the patients presented with pain. To heighten physician awareness regarding spinal epidural hematoma and spinal epidural abscess, the Canadian Medical rotective Association established a broad list of guidelines to assist with the diagnosis 8 : (1) patients presenting with back pain and unexplained fever; (2) symptoms associated with intravenous drug abuse, diabetes mellitus, recent spinal surgery or spinal anesthesia, or recent bacteremia; (3) facilitate timely diagnosis and treatment with magnetic resonance imaging or computed tomography scan, neurological consultation, and admission to hospital. 4 Once diagnosis is confirmed, arrange for urgent neurosurgical or orthopedic consultation. Other recognizable clinical features include fever, spinal pain or tenderness, radiating root pain, and limb weakness. 3 In this study, location of the spinal lesion was not an indicating factor in the medicolegal verdict. However, it could prove to be beneficial diagnostically. Only 20% of spinal lesions occur anterior to the spinal cord and are more frequently associated with vertebral osteomyelitis This would present with more systemic clinical features compared with posterior spinal lesions of the thoracic and lumbosacral region. In the cases reviewed, the majority of spinal lesions were located at the cervical and lumbosacral region, which differs from previous literature. 1 The loss of function varied between the cases presented and the various spinal cord lesions. It is important to note that most of the individuals who initially presented to a medical professional were seen in the emergency department (58%) or outpatient setting (32%). Therefore, it is important for all medical professionals to maintain a high level of suspicion and act quickly. The most important factor for prognosis and litigation outcomes is to diagnosis and treat the patient within 48 hours. atients who were misdiagnosed or were not offered treatment within 48 hours of onset of symptoms won their litigations 100% of the time. The only instance in which the defendant was exempted from an adverse verdict is when the patient or family did not file a lawsuit within an appropriate amount of time or failed to present accurate documentation of evidence. It is apparent that the legal system is not interested in the loss of function, temporary or permanent neurological deficit acquired, or lack of physical examination performed (rectal examinations were not performed in any case). The only influential factor is the ability to diagnose a patient with spinal epidural hematoma or spinal epidural abscess and treat. Limitations to this study included its retrospective nature; legal cases involving spinal epidural hematoma and spinal epidural abscess are difficult to locate. Although the LexisNexis Academic database is an excellent source to locate lawsuits, the consistency of the background information (ie, timeline of events) varied from case to case. Conclusion Spinal epidural hematoma and spinal epidural abscess are rare medical emergencies that are difficult to clinically diagnose. A patient with escalating pain, fever, and limb weakness with no identifiable source must be suspected for spinal epidural hematoma or spinal epidural abscess. A systematic algorithm would prove useful to workup and diagnose individuals with more than 1 risk factor or predisposing condition enhancing their probability. hysicians of every specialty, especially those working in the emergency department or outpatient settings, can protect their practice and integrity by trying to establish a diagnosis and appropriate treatment of spinal epidural hematoma or spinal epidural abscess within 48 hours of presentation. 52 ORTHOEICS Healio.com/Orthopedics

6 Spinal Epidural Hematoma and Spinal Epidural Abscess French et al References 1. Sendi, Bregenzer T, Zimmerli W. Spinal epidural abscess in clinical practice. QJM. 2008; 101(1): Bluman EM, alumbo MA, Lucas R. Spinal epidural abscess in adults. J Am Acad Orthop Surg. 2004; 12(3): Mackenzie AR, Laing RB, Smith CC, Kaar GF, Smith FW. Spinal epidural abscess: the importance of early diagnosis and treatment. J Neurosurg sychiatry. 1998; 65(2): arouiche RO. Spinal epidural abscess. N Engl J Med. 2006; 355(19): Chao, Nanda A. Spinal epidural abscess: a diagnostic challenge. Am Fam hysician. 2002; 65(7): Al-Mutair A, Bednar A. Spinal epidural hematoma. J Am Acad Orthop Surg. 2010; 18(8): Baker AS, Ojemann RG, Swartz MN, Richardson E Jr. Spinal epidural abscess. N Engl J Med. 1975; 293(10): Fong IW. iscussion of medicolegal issues. In: Springer, ed. Medico-Legal Issues in Infectious iseases: Guide for hysicians. Toronto, Canada: Springer Science; 2011: anner RL, Hartman BJ. Update of spinal epidural abscess: 35 cases and review of the literature. Rev Infect is. 1987; 9(2): Soehle M, Wallenfang T. Spinal epidural abscesses: clinical manifestations, prognostic factors, and outcomes. Neurosurgery. 2002; 51(1): Hlavin ML, Kaminski HJ, Ross JS, Ganz E. Spinal epidural abscess: a ten-year perspective. Neurosurgery. 1990; 27(2): JANUARY 2013 Volume 36 Number 1 53