Spinal Epidural Abscess: A Time Sensitive Diagnosis

Katie’s Story: A Life Forever Changed by Spinal Epidural Abscess

A Joyful Day Takes a Terrifying Turn

Katie*, a healthy 35 year old mom of two, is celebrating the fourth of July with her family, swimming in the pool with her daughters. As she steps out of the pool, she notices that her toes and feet are numb. While her mom watches her kids, she heads inside to change out of her swimsuit. When her ankles start to feel numb, she gets worried. They head to the hospital.

Katie has no idea that her life is about to change forever. A week later, she’ll find herself in a neuro ICU, being told that she will probably never walk again. She’ll have to learn a lot of new things, like how to self-catheterize, since she can no longer hold her own urine. She’ll have to learn how to navigate life without the use of her legs.  She’ll find out that her home simply wasn’t designed for someone in a wheelchair: the doorways are too narrow, the cabinets and counters too high. The beautiful garden tub she used to love soaking in is now a useless deathtrap.

The Shocking Diagnosis: Spinal Epidural Abscess

A bacterial infection seeded in the “dura” of Katie’s spine– a tubular membrane that encases the spinal cord. That infection created an abscess, or a collection of pus, that was pressing against Katie’s spinal cord, causing the numbness in Katie’s feet. The longer it’s there, pressing on her spinal cord, cutting off oxygen-rich blood supply, the worse her prognosis for recovery becomes.

Diagram of a Spinal Epidural Abscess

The Chain of Delays

Delays in the Emergency Room

Timing is critical in cases involving delayed diagnosis of spinal epidural abscess. An ER physician can diagnose a spinal epidural abscess once he or she recognizes the possibility and orders an MRI, which will show the abscess. However, definitive treatment is rendered by neurosurgeons. There are lots of potential sources of delay in treating this time sensitive problem:

  • ER physician does not order the proper test—an MRI—which will show the abscess;
  • MRI isn’t available at the facility at all;
  • MRI isn’t available in a timely manner—either because it isn’t staffed with available technicians, or because the test wasn’t prioritized (ordered STAT);
  • Neurosurgery service is not available at the treating facility, and the patient must be transferred elsewhere;
  • Neurosurgery services are limited at the hospital—maybe there’s only 1 neurosurgeon on call—and they aren’t responding quickly to the emergency;

Not all of these “delays” are necessarily negligent. For instance, many hospitals have no neurosurgery services, or have very limited neurosurgery services. This is understandable in many communities, particularly rural ones. However, not having access to a service means hospitals should be prepared to transfer a patient as quickly as is reasonably possible. Similarly, hospitals that make financial decisions to only have MRI services available at certain hours of the day must make arrangements to perform those services quickly when patients have emergency need of those services “after hours.”

The Critical Role of MRI Availability & Transfer Dilemma

As the hours wore on at her local hospital, the numbness slowly crept up her spine until it reached her chest. Finally, a neurologist who was asked to see the patient ordered an MRI. Unfortunately, however, the MRI wasn’t staffed at night, and it wasn’t until the morning that Katie’s MRI was performed, showing the massive abscess pressing on her spine. At that point, because a neurosurgeon wasn’t available at the local facility, the hospital needed to transfer her to a local facility that had a neurosurgeon willing to accept her and perform surgery.

As you can see, numerous delays played into Katie’s case. While Katie rushed to get care promptly, the ER physician didn’t suspect her of having an epidural abscess, and failed to “rule out” this “don’t miss” diagnosis by not ordering an MRI. Physicians are trained on the classic “triad” of symptoms: fever, back pain, and neurologic deficits. However, this “classic” triad is a misnomer, because patients rarely present with all three symptoms.

Katie, for instance, lacked a fever. Physicians are also trained that a common pathway for bacteria to enter the dura is through intravenous drug use, and therefore, the diagnosis becomes more likely in someone who reports IV drug use. However, while IV drug use is one way that bacteria can enter the dura, it’s not the only way. Any open wound—even something as minor as an ingrown toenail or cut—could be a pathway for bacteria to enter the blood stream. Often, the source of the infection remains unknown.

A second delay came into play when the MRI that was ordered by a neurologist who was consulted was not ordered “stat.” Because it was night time, the MRI suite was not staffed, and technicians were only called in for emergent tests. Thus, the MRI was delayed until the following morning.

A third delay came into play when the hospital wasted time trying to transfer Katie to an in-network facility. Only fifteen minutes down the road, a competitor hospital offered neurosurgery services, and Katie could have been transferred there in an ambulance, but that facility wasn’t called. Instead, a hospital call center spent hours speaking with other hospitals owned by the same company, to see if they had neurosurgeons available.

Legal and Medical Perspectives Regarding a Spinal Epidural Abscess

Assessing the Delays

While all of these delays are compelling and tragic, as lawyers, we must also understand the science. At a given point in any patient’s care, it becomes too late to make a difference. The most important delays in Katie’s case were the ones that occurred in the emergency department, because at that point, her numbness had just began and was just in her feet. The best indicator of a patient’s outcome is their condition just prior to surgery. Therefore, even though the delays later on in the story are frustrating, it would be much harder to prove they made a difference in her outcome. These issues are frequently the subject of great debate among neurosurgery experts.

The Importance of Timely Medical Attention

Timing is everything in spinal epidural abscess cases. While this article focuses on hospital and physician delays, it’s also important for patients to get medical attention quickly. When a patient presents with symptoms that have been present for months, there is little a surgery can do to improve their condition, although it may still be indicated to prevent symptoms from getting worse.

Paul | Knopf | Bigger - Florida Injury AttorneysIf you or a loved one has been left with life-changing impairments after surgery to address a spinal epidural abscess, we highly recommend you contact an experienced medical malpractice attorney at Paul | Knopf | Bigger to review the specific facts of your case and carefully examine the care you received.  We were able to help Katie and her family get the financial help they needed to adjust to their new normal as comfortably as possible.

*Katie’s name has been changed