A Pain in the Neck Becomes a Pain in the Pocketbook

A man presented to the emergency department complaining of debilitating neck pain that radiated to his shoulders. He denied history of injury. This patient had a history of diabetes, and said that the pain was worse when he sat, and asked for “Demerol.” He denied having any weakness, chest pain, shortness of breath, or vomiting.

The man’s vital signs showed a temperature of 100.2, respirations of 20, and blood pressure of 130/70. An examination of his head, eyes, ears, nose, and throat were normal. His breath sounds were equal, his heart had a regular rate and rhythm, and his abdomen was soft and non-tender. He had full range of motion in his extremities, good bilateral hand strength, and he was awake, alert, and oriented. The notes indicated that he had bilateral muscle spasm and guarding of the neck.

The Prescription Drug Monitoring Program (PDMP) revealed that the patient had received several prescriptions for pain medications over the past year, but there were no older records at this hospital.

The emergency department physician treated the patient with ketorolac and diazepam. The patient was reevaluated an hour later and reported that the pain had improved. The patient was diagnosed as having a neck strain and spasm. He was discharged with a prescription for muscle relaxants and instructed to see his primary care physician (PCP) for further evaluation if the pain did not improve or worsened.

The patient’s wife called the PCP the next day and said that her husband had persistent neck pain. The PCP’s office booked an appointment three days out and instructed his wife to have him continue taking the medications.

Two days later, the patient came to the emergency department with weakness in all four extremities. An MRI revealed an epidural abscess from C5-T1. The patient went directly to surgery, and was left with severe quadraparesis.

The exact details of the case are confidential, but the emergency physician and the internist settled for around $3 million.

Spinal Abscesses and Spinal Injuries Rank Among the Top Ten Most Frequent Causes of Law Suits

Spinal epidural abscesses and other spinal cord injuries have broken into the top ten reasons that emergency medical malpractice dollars are paid out. The failure to diagnose and treat epidural abscesses in a timely manner, resulting in paraplegia or incontinence, is now fourth on the internal medicine list of diagnosis-related claims.

Back and neck pain are among the top five most common reasons patients visit the emergency department. Diagnosis can be difficult, as many patients present with a vague history of possible trauma and often present with a history of either drug abuse or alcoholism. Less common risk factors include malignancy, end-stage renal disease, epidural anesthetics, vascular access, spinal trauma, and degenerative joint disease.

Epidural abscesses often develop from a separate infection site that has spread hematogenously. Frequently, the culprit is skin or soft tissue infections (most common), respiratory tract infections, or urinary tract infections. Often, it is not possible to identify the site of the infection, making diagnosis on the first visit difficult. Only about 30% of patients have fever. About 20% of patients have a history of minor trauma and almost an equal number have a history of chronic pain.

Physical Exam

It is important to remember that the entire physical examination is less useful in making the diagnosis than a history of urinary retention. Nevertheless, the physical examination should include a detailed neurological exam that specifically seeks out sensory and motor deficits, including saddle anesthesia and diminished rectal tone. Special attention should be paid to potential infection sites, including the lungs, skin, and musculoskeletal system.

Diagnostic Studies

Consider ordering a CBC, an ESR, and blood cultures. In spinal epidural abscesses, WBC can be normal 40% of the time, but the majority of studies conclude that the ESR is almost always elevated. Blood cultures help guide antibiotic therapy. Gadolinium-enhanced MRI is the imaging modality of choice, but if MRI is unavailable, CT with contrast is a good alternative. Lumbar puncture is generally contraindicated.

Management

Surgical drainage of confirmed epidural abscesses should occur within 24 hours of presentation. Neurosurgical consultation is considered the gold standard. For small abscesses, interventional radiology may be another option.

Although spinal epidural abscess infections are usually caused by a single organism (most often S. aureus), broad-spectrum antibiotics covering for E. coli and P. aeruginosa should be administered. Vancomycin combined with a cephalosporin with antipseudomonal activity (ceftazidime or cefepime) is usually the best choice. Regardless of antibiotic selection, the duration of treatment is usually a minimum of four to six weeks. Shorter courses or non-compliance may lead to recurrences.

The Bottom Line

Epidural abscess should always be considered for potentially immunocompromised patients with atraumatic neck or back pain. Diabetics, alcoholics, and IV drug users are at highest risk.

A thorough history and physical on all patients should be completed; be wary of biases relating to patients who have a history of potential drug-seeking behavior. Always recommend prompt follow-up with new onset atraumatic pain and provide explicit instructions to return for fever, weakness, or increasing pain.

MRI is the imaging study of choice and there are several reasons to consider ordering an MRI of the entire spine. There may be skip lesions, and sometimes, the physical exam is not consistent with the location of the abscess. If MRI is not available, then CT with contrast is usually diagnostic. Some argue that ESR may be used as a screening test to rule out spinal epidural abscesses.

Always do a complete exam on a patient who has a fever or infectious condition and has back pain or physical weakness. Don’t be distracted from considering the diagnosis of spinal epidural abscess by an obvious skin, pulmonary, or urinary tract infection. It is easy to blame the back pain on pyelonephritis.

The Monster Claim is the nightmare, $1,000,000 plus settlement or judgment (not including defense costs) that could happen to any unsuspecting physician or medical care provider. As in most cases in emergency medicine, it is a case of failure to suspect the diagnosis and involves a series of unfortunate events. We believe that it is important that all emergency providers become aware of these claims so they won’t repeat the same mistakes in the future.

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