Physician History: A 40-year-old woman presented to the ED at 0400 with the complaint of right lower back pain, rated a 7 out of 10. It was worse with cough and improved with sitting. There was no recent trauma and no apparent precipitating event. She told the emergency physician that she had weakness in her legs, but that it was “unchanged” and nonfocal. Her legs felt “very heavy.” She said she had similar symptoms in the past that resulted in aspiration pneumonia 3 years ago; that required surgery to “drain her lungs.” She said she had an ongoing cough and shortness of breath that had not changed that she felt were related to smoking.
Review of Systems: No problem with gait; neuro review was negative for weakness, lightheadedness, numbness and headaches. No urine or fecal incontinence. No numbness or tingling.
Triage Vital Signs:
Physical Exam: The physician noted: “Vital signs are normal.” The patient was morbidly obese.
Musculoskeletal: Normal ROM. No tenderness. Lumbar area exhibits tenderness (drawing of low back with arrow pointing to just above the iliac crest).
Neuro: Alert, no cranial nerve deficit. Coordination normal. There were no motor, sensory, reflex or gait exams.
ED Course: WBC 15.7; glucose 236. CXR negative. Patient was treated with an albuterol nebulizer.
Medical Decision-Making: Patient is concerned about pneumonia. The differential diagnosis includes pulmonary embolism, pneumonia, pleural effusion, UTI, back strain. CXR unremarkable. Patient condition stable and will be discharged home. Instructed patient to follow up with her primary care physician for weakness in her legs. Prescribed a nebulizer for SOB and a Z-Pak.
RN Notes. “Pt. reports mid back pain X 3 days, right > left, increasing with cough and laying down. Clear sputum. History of same pain, diagnosed with pneumonia at that time, 3 years ago. She denies shortness of breath and chest pain.”
On Day 4 the patient returned to the same ED.
Physician History: 40-year-old female with hypertension, diabetes with neuropathy, with back and abdominal pain. Bilateral low back pain began 1 week ago and radiates into her lower abdomen. Acutely worsened and became constant today at 2:00 pm. Associated urinary frequency, unable to lay flat. Similar pains a few years ago; diagnosed with pneumonia. Concerned about kidney infection, stones or nerve impingement in back. No relief with NSAIDS or with antibiotics given a few days ago. “Denies any associated numbness, tingling, urinary or bowel incontinence, or saddle anesthesia.”
Review of Systems: No focal weakness or loss of consciousness
Physical Exam:
No distress.
Lungs: Mild wheeze, otherwise clear to auscultation
Heart: NSR
Abdomen: Non-tender, +right CVA tenderness
Neurologic: Moving all extremities, no gross neuro deficit
ED Course: Normal white count, glucose 377. UA negative. Renal CT negative. Patient received IV fluids, Toradol, insulin and Dilaudid for continuing pain.
Medical Decision-Making: Felt better after second round of meds. Advised to follow up with her primary care physician on Monday and to possibly pursue MRI should she not improve. Additionally, she may have a UTI, which is masked by current or recent antibiotics. Therefore, she will be provided with antibiotics at discharge to treat for possible UTI or pyelo. She was treated with Bactrim, Toradol and Flexeril.
PA Exam: 40-year-old complaining of acute and chronic atraumatic back pain for several days. Patient states she does not know why she did not call her clinic physician today. Pain is 7 out of 10, nonradiating and constant. Worse with ambulating or range of motion. Denies trauma, numbness, tingling of bilateral lower extremities. No loss of bowel or bladder function; no saddle anesthesia or loss of sensation or strength bilateral lower extremity. No fever, weight loss, malaise, night sweats, diaphoresis or shortness of breath. No chest pain, nausea, emesis, recent or long-term steroids, or osteoporosis.
Review of Systems: Otherwise negative.
Physical Exam:
On physical exam, the PA noted musculoskeletal exam “normal range of motion.”
Neurologic Exam: He noted: “She is alert.”
Clinic Course: “Patient had paraspinous tenderness at L3-5 without midline spinous process tenderness. I did not order imaging due to no new trauma and patient is neurovascularly intact on physical exam. Patient was observed ambulating to and from the bathroom. Epidural abscess was considered however excluded based on no history of fever and no history of IV drug abuse.”
Patient was discharged on Ativan and Dilaudid. Discharge instructions: Return for leg weakness, numbness, fever, chills, or bowel or bladder incontinence.
The patient presented to the emergency department later that same day. The physician noted in his history of present illness the patient had been discharged earlier today, presents after falling in driveway. She has lumbar back pain for 9-10 days, radiating down both legs. The physician addressed the period of time following discharge from the PA clinic. She drove home; she was unable to feel her legs and ended up falling out of the car onto the driveway.
Her mid lumbar back pain worsened this morning when she was walking in her kitchen. She noted a snap and had sudden lumbar back pain that radiated to her legs bilaterally with associated numbness. She was able to walk to the bathroom without difficulty and urinate; however, she could not get up from the toilet. States that later she urinated on herself and was not aware of this.
Review of Systems: Otherwise negative.
Physical Exam:
Back Exam: Left lumbar tender, unable to lift legs. Unable to dorsiflex great toes bilaterally or move legs. Denies sensation in both legs, but able to sense pinprick. Normal patellar DTRs; absent Achilles DTRs; upgoing Babinski on the right, downgoing on the left.
Neurologic Exam: Bilateral upper and lower extremity 5/5 strength, no gross neuro deficit.
Sinus tachycardia at 124. Urinalysis: elevated sugar. Lactate: 1.0. White blood cell count: 17,000.
CMP: Bicarbonate 19; glucose 285. Sed rate: 43.
MRI of the lumbar spine T12-L5 showed L5-S1 disc desiccation and mild loss of disc height as well as a focal posterior midline protrusion, which indents the thecal sac; however, it does not significantly narrow the central canal and degenerative joint disease.
ED Course: Reviewed the differential diagnosis and reviewed labs. Noted that the patient could not ambulate, was felt to have possible pneumonia, and was started on antibiotics and transferred to inpatient at an outlying hospital. Diagnosis: acute lumbosacral back pain, inability to ambulate, pneumonia.
The physician at the receiving hospital documented an admission history and physical exam. He documented significant neurologic deficits and the prior “unremarkable MRI.” There was uncertainty about the cause, and there was a plan to ask for a neurologic consultation.
The next day the patient was seen by a neurologist who documented in a progress note. He noted: “Sensory exam is noticeably different from yesterday’s exam.” He noted the patient did not appear to be making an effort when he asked her to flex at the hips and that there were a number of discrepancies in her exam. He concluded, “Although patient may have a lumbosacral radiculopathy nerve process, I believe her presentation is suggestive of embellishment or functional disorder.”
The patient’s neurologic condition continued to deteriorate. On day 9, she had an MRI that showed an epidural mass from C6-T10, which was initially called a hematoma by the radiologist. On further review, she was found to have a large SEA, which was reported to the hospitalist. There is an operative note from later in the day that describes evacuation of the abscess.
This is a relatively recent case, and the patient’s outcome is unknown. It is also not known whether there is any litigation currently pending in the matter.
Spinal epidural abscess can be a very difficult diagnosis to make. It is simply not fair to say that the diagnosis should have been made during visit #1 or visit #2. The patient never complained about fever or shaking chills. However, the patient complained during visit #1 of back pain without a precipitating cause, a lower extremity complaint that could have had a spinal etiology, tachycardia, and an elevated white blood cell count. Perhaps the physician was caught by the search satisficing heuristic. With a normal chest X-ray, no purulent sputum, and no fever, his first consideration was pneumonia; that is, once satisfied that the search for a diagnosis may be over, the physician stopped the diagnostic thought process. The diagnosis of pneumonia simply does not explain the patient’s low back and lower extremity symptoms. Tachycardia was never addressed in the physician’s medical decision-making, and the vital signs were never repeated by nursing.
Many cases of failure to diagnose SEA are complicated by MRI imaging at the wrong spinal level. There is absolutely a common thread in failure to diagnose SEA cases. Practitioners typically order an MRI of the lumbar spine when, in fact, the abscess is at a higher level in the spine or is at multiple levels in the spine. Review of the literature does not provide any standard with regard to which levels of the spine should be imaged when considering the possibility of a spinal epidural process. There have been efforts to come up with a prediction rule with regard to spinal epidural abscess and consideration of pan-spine MRI. However, there is simply not enough literature to justify that as a recommendation.
It appears that the physician assistant simply missed a neurologic deficit, although that is in part conjecture. What is striking is his thorough neurologic documentation that suggested the patient had no neurologic problems. Perhaps this is a result of EMR overuse syndrome; in other words, it may simply have been easy to check a box and get a completely normal neurologic system documented through the electronic medical record system.
We present this case not to point a finger at any particular individual or visit, but rather to continue to raise awareness of the failure to diagnose problem in general and to take another look at the failure to diagnose spinal epidural abscess specifically. It is through this type of analysis, a cognitive autopsy if you will, that we can learn to recognize the red flags in cases of concern in the failure to diagnose arena.
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