Medicolegal Cases for Spinal Epidural Hematoma and 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 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 2010. 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 P 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) ( P =.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 ( P =.268). Of 19 cases, 14 (74%) presented with 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 ( P =.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 ( P =.878 and .568, respectively).

Table 1: Comparison of Cases Won by the Plantiff Versus the Defendant

Table 2: Complete List of Reviewed Cases

The only statistically significant risk factor influencing litigation decisions was a time to surgery greater than 48 hours ( P =.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.

Discussion

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. Physicians 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 Protective 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. ^9–11 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. Patients 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. Physicians 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.