Evaluation and management of spinal epidural abscess

DeFroda, Steven F.; DePasse, J. Mason; Eltorai, Adam E.M.; Daniels, Alan H.; Palumbo, Mark A.

doi:10.1002/jhm.2506

Cited by 27 publications

(44 citation statements)

References 38 publications

(81 reference statements)

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“…While the condition can be managed conservatively with intravenous (IV) antibiotics in select cases, urgent surgical decompression (combined with antimicrobial therapy) is typically the treatment of choice. 2 SEA often presents a diagnostic challenge, as the "classic triad" of fever, back pain, and neurological deficit is present in only 13%-37% of patients. 2 A delayed or missed diagnosis 2 may lead to poor patient outcomes and a high risk for litigation.…”

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confidence: 99%

Assessment of malpractice claims due to spinal epidural abscess

DePasse

Ruttiman

Eltorai

et al. 2017

Journal of Neurosurgery: Spine

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OBJECTIVESpinal epidural abscesses (SEAs) can be difficult to diagnose and may result in neurological compromise or even death. Delays in diagnosis or treatment may worsen the prognosis. While SEA presents a high risk for litigation, little is known about the medicolegal ramifications of this condition. An enhanced understanding of potential legal implications is important for practicing spine surgeons, emergency medicine physicians, and internists.METHODSThe VerdictSearch database, a large legal-claims database, was queried for “epidural abscess”–related legal cases. Demographic and clinical data were examined for all claims; any irrelevant cases or cases with incomplete information were excluded. The effects of age of the plaintiff, sex of the plaintiff, presence of a known infection, resulting paraplegia or quadriplegia, delay in diagnosis, and delay in treatment on the proportion of plaintiff rulings and size of payments were assessed.RESULTSIn total, 56 cases met the inclusion criteria. Of the 56 cases, 17 (30.4%) were settled, 22 (39.3%) resulted in a defendant ruling, and 17 (30.4%) resulted in a plaintiff ruling. The mean award for plaintiff rulings was $5,277,468 ± $6,348,462 (range $185,000–$19,792,000), which was significantly larger than the mean award for cases that were settled out of court, $1,914,265 ± $1,313,322 (range $100,000–$4,500,000) (p < 0.05). The mean age of the plaintiffs was 47.0 ± 14.4 years; 23 (41.1%) of the plaintiffs were female and 33 (58.9%) were male. The proportion of plaintiff verdicts and size of monetary awards were not affected by age or sex (p > 0.49). The presence of a previously known infection was also not associated with the proportion of plaintiff verdicts or indemnity payments (p > 0.29). In contrast, juries were more likely to rule in favor of plaintiffs who became paraplegic or quadriplegic (p = 0.03) compared with plaintiffs who suffered pain or isolated weakness. Monetary awards for paraplegic or quadriplegic patients were also significantly higher (p = 0.003). Plaintiffs were more likely to win if there was a delay in diagnosis (p = 0.04) or delay in treatment (p = 0.006), although there was no difference in monetary awards (p > 0.57). Internists were the most commonly sued physician (named in 13 suits [23.2%]), followed by emergency medicine physicians (named in 8 [14.3%]), and orthopedic surgeons (named in 3 [5.4%]).CONCLUSIONSThis investigation is the largest examination of legal claims due to spinal epidural abscess to date. The proportion of plaintiff verdicts was significantly higher in cases in which the patient became paraplegic or quadriplegic and in cases in which there was delay in diagnosis or treatment. Additionally, paralysis is linked to large sums awarded to the plaintiff. Nonsurgeon physicians, who are often responsible for initial diagnosis, were more likely to be sued than were surgeons.

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confidence: 99%

Assessment of malpractice claims due to spinal epidural abscess

DePasse

Ruttiman

Eltorai

et al. 2017

Journal of Neurosurgery: Spine

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“…5 Cases treated with early surgery typically achieve better outcomes than cases treated without surgery. 9 Especially in patients who are older than 65 years, suffer from diabetes, are infected with methicillin-resistant Staphylococcus aureus, or show neurological deficits, nonsurgical medical management is not recommended.…”

Section: Discussionmentioning

confidence: 99%

A spinal epidural abscess due to Streptobacillus moniliformis infection following a rat bite: case report

Hammer

Wolff

Geißdörfer

et al. 2017

Journal of Neurosurgery: Spine

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The authors describe the case of a 40-year-old man suffering from an epidural abscess in the thoracic spine due to a rarely isolated pathogen, Streptobacillus moniliformis, the causative agent of rat bite fever. Besides diffuse abdominal pain, ataxia, paresthesia, hypesthesia, and enhanced reflexes of the lower extremities, the patient suffered from a decreased sensation of bladder filling. His history was also positive for a rat bite 6 weeks earlier. Magnetic resonance imaging showed an epidural, space-occupying lesion compressing the spinal cord at the vertebral levels of T6–8. Neurosurgery revealed an epidural abscess, which was drained via laminectomy (T-7) and excision of the ligamentum flavum (T6–8). The etiological agent S. moniliformis was identified by 16S rRNA-based polymerase chain reaction and sequencing as well as by culture and mass spectrometry. Treatment with penicillin G led to complete resolution of the abscess and clinical recovery of the patient, who regained his bladder-filling sensation and free walking ability.This case demonstrates that careful attention to the patient's history is essential in suspecting unusual bacterial pathogens as the cause of an epidural abscess and initiating the optimal diagnostic procedure and antimicrobial therapy.

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“…7 Antibiotics are administered for 4-6 weeks. 5 Four risk factors have arisen to predict failure of medical management of SEA: diabetes mellitus, leukocytosis greater than 12.5 × 10 3 /μL, positive blood cultures, and C-reactive protein N115 mg/L. 7 Delay in surgical intervention has been found to limit functional recovery when compared with immediate surgical intervention.…”

Section: Discussionmentioning

confidence: 99%

“…A history of diabetes mellitus (21%-38% of cases), intravenous (IV) drug use, end-stage renal disease, human immunodeficiency virus (HIV), or immunosuppressant use and iatrogenic causes, such as epidural spinal procedures, increase the risk of SEA. [5][6][7] Cases of SEA have been documented as presenting to chiropractic offices often masquerading as non-specific neck or back pain. [8][9][10] The classic clinical triad of back pain, fever, and neurological deficits is observed in only~10% of cases.…”

Section: Introductionmentioning

confidence: 99%

“…A computed tomography (CT) myelogram should be obtained when MRI is unavailable or is contraindicated because of an implanted electrical device (eg, pacemaker, spinal stimulator). 5,11,15 The infectious agent causing SEA is most commonly of bacterial origin and overwhelmingly either methicillin-sensitive or methicillin-resistant Staphylococcus aureus. 7,13 Once patients are diagnosed with SEA, best outcomes are achieved with rapid surgical intervention, abscess drainage, and concomitant antibiotic treatment.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report

Cupler

Anderson

Stancik

2017

Journal of Chiropractic Medicine

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Objective: The purpose of this case study was to describe the differential diagnosis of a thoracic epidural abscess in a Navy veteran who presented to a chiropractic clinic for evaluation and management with acupuncture within a Veterans Affairs Medical Center. Clinical Features: An afebrile 59-year-old man with acute thoracic spine pain and chronic low back pain presented to the chiropractic clinic at a Veterans Affairs Medical Center for consideration for acupuncture treatment. Intervention and Outcome: The veteran elected to trial acupuncture once per week for 4 weeks. A routine thoracic magnetic resonance imaging scan without gadolinium detected a space-occupying lesion after the patient failed to attain 50% reduction of pain within 2 weeks with conservative care. The patient was diagnosed with a multilevel thoracic spondylodiscitis epidural abscess and was treated same day with emergency debridement and laminectomy of T7-8 with a T6-9 fusion. The patient had complete recovery without neurological compromise and completed an antibiotic regimen for 6 weeks. Conclusion: A Navy veteran with acute thoracic spine and chronic low back pain appeared to respond initially but failed to achieve clinically meaningful outcomes. Follow-up advanced imaging detected a thoracic spondylodiscitis epidural abscess. Early diagnosis and immediate intervention are important to preserving neurological function and limiting morbidity in cases of spondylodiscitis epidural abscess. (J Chiropr Med 2017;16:246-251)

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Evaluation and management of spinal epidural abscess

Cited by 27 publications

References 38 publications

Assessment of malpractice claims due to spinal epidural abscess

Assessment of malpractice claims due to spinal epidural abscess

A spinal epidural abscess due to Streptobacillus moniliformis infection following a rat bite: case report

Thoracic Spondylodiscitis Epidural Abscess in an Afebrile Navy Veteran: A Case Report

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