Case Study: Lost Information In Spinal Epidural Abscess Case

The Error, Stated Plainly

Somewhere between two Pennsylvania hospitals, one piece of information disappeared.

It was not a subtle finding. A CT scan had shown a destructive mass eating through the bones of a man’s upper spine. The radiologist who read it wrote that it could be cancer, or it could be infection, and recommended an MRI to determine whether the spinal canal itself was involved.

Days later, when that man was transferred from the first hospital’s emergency department to a larger hospital that could do the workup, the images did not go with him. Neither did the report. Neither did the word infection.

What arrived instead was a patient with severe back pain and a general description of a mass. The physicians who admitted him spent the next two days treating what they believed was a tumor, with escalating doses of narcotics and a plan to repeat imaging on a non-urgent basis.

It was not a tumor. It was a bacterial infection that had eaten through his spine and formed an abscess pressing directly against his spinal cord. Every hour it went unrecognized, it was strangling the nerves running to his legs.

He was a man who walked into that first emergency department on his own two legs, without assistance, describing pain in his upper back that felt like electric shocks. By the time anyone ordered the MRI that would have revealed the abscess, he was paralyzed from the chest down. Permanently.

That contrast, a man arriving upright under his own power and leaving permanently paralyzed by a condition that antibiotics and timely surgery routinely treat, is the whole case.

What a Spinal Epidural Abscess Does, and Why Hours Matter

Spinal epidural abscess is not an exotic diagnosis. It is a recognized emergency that every emergency physician and every hospitalist is trained to look for.

An epidural abscess is a collection of pus in the space between the outer covering of the spinal cord and the bone of the spinal canal. That space cannot expand, so the collection compresses the cord and the vessels feeding it. The injury comes from two directions at once, meaning direct mechanical pressure plus loss of blood supply to nerve tissue that tolerates ischemia very poorly.

Bacteria usually arrive through the bloodstream from an infection somewhere else, or they spread from adjacent infected bone or disc space. Risk factors include diabetes, immune compromise, recent bacteremia, indwelling lines, recent surgery or an open wound, and prior spinal instrumentation. Often the organism is an ordinary staph species that standard antibiotics kill readily, provided someone knows it is there.

The classic teaching is a triad of back pain, fever, and neurological deficit. The trap is that the full triad shows up in only a minority of patients when they first seek care. Far more often the patient has the first element alone, meaning severe, unremitting back pain that is out of proportion to the examination and not relieved by ordinary doses of pain medication.

The progression is well described and stepwise. Localized spinal pain, then radiating nerve root pain, then motor weakness and sensory loss and bowel or bladder dysfunction, then paralysis. That last step is often abrupt, and it is frequently permanent.

This is why time is of the essence. Once a complete neurological deficit develops, the window for meaningful recovery closes fast, and the literature measures it in hours rather than days. A patient decompressed while still walking usually walks afterward. A patient decompressed after complete paralysis has set in usually does not. The correct response to suspicion is an urgent MRI with contrast and an immediate surgical consultation, not observation and not more pain medication.

One more piece matters here. Inflammatory markers are elevated in the overwhelming majority of these patients. They are not specific to abscess, but in a patient with spinal pain and a destructive spinal lesion, significantly elevated markers point toward infection rather than tumor, and they demand that infection be ruled out rather than assumed away.

Two Days on the Ward

He first came to a community-based emergency department with pain between his shoulder blades sharp enough that it hurt to breathe.  Imaging found the destructive spinal lesion, and the radiologist’s differential included both malignancy and infection, with a recommendation for MRI of the thoracic spine to assess the spinal canal. The emergency physician recommended transfer to a larger hospital that could complete that workup. Frightened and confused, the man decided to go home instead.

Four days later he came back to the ED. The pain was now the worse than a 10/10. This time he agreed to be transferred to a larger hospital.

The MRI images and the report describing them did not travel with him to the larger hospital. The sending ED did not communicate to the receiving hospital that the scan had been read as suggestive of vertebral osteomyelitis and discitis.

Within the first hour and a half after he arrived, the nursing intake assessment documented weakness in both legs and recorded that he needed help getting in and out of bed. That was a level of dependence this middle-aged man had not had days earlier.

Minutes after that assessment was charted, the admitting physician wrote an admission history and physical.  He noted the outside imaging and report had not been sent with the patient. The neurological examination recorded in that note was that the patient was awake, oriented, and in no acute distress. There was no strength testing. No sensory testing in any distribution. No examination of the spine at all, in a man admitted for spinal pain from a known spinal lesion. No review of systems for weakness or numbness, even though nursing had documented leg weakness in the same chart roughly an hour earlier.

Spinal cord compression never appeared on the differential. No neurosurgeon was called. The plan was pain control and repeat imaging, non-urgently.

Later that night, bloodwork returned showing markedly elevated inflammatory markers, which is the laboratory signature of an aggressive infection rather than a tumor.

The next day a second hospitalist took over. He documented that the pain was not controlled and escalated the narcotics. His neurological examination was recorded as normal strength, without reference to which muscle groups were tested, without grading them on any recognized scale, and without sensory testing. Across that same day, at multiple charting intervals, nurses documented the strength in the patient’s feet as only moderate.

Still no urgent MRI. Still no neurosurgical consultation. Still no consideration of cord compression.

Overnight the nursing documentation kept recording diminished foot strength. By the afternoon of the next day, he could barely wiggle his toes, and numbness in both legs was documented for the first time.

Shortly after that, a different physician examined the patient and documented what had gone unnoticed for two days. He was paraplegic. His deep tendon reflexes were absent. He had no sensation below the mid-chest. That physician recommended an immediate thoracic spine MRI.

The MRI was done that afternoon. The radiologist called in critical findings, meaning infection of the disc space and vertebral bone with pathologic fracture, extensive epidural abscess, severe narrowing of the spinal canal with cord compression, and probable swelling of the cord itself, with a recommendation for emergency neurosurgical consultation.

Surgeons took him that night, decompressed the spine, and washed out a large thoracic epidural abscess. Cultures grew a common staph organism, the kind ordinary antibiotics eliminate reliably when someone knows to give them.

The surgery came too late. The nerve tissue was already dead.

Where Our Law Firm Came In

The family came to our lawyers looking for an explanation. They had been told that he had a spine infection, that it was serious, and that these things happen. No one had told them that he had walked into a hospital on his own, and that the hospital then had two full days, and a chart already documenting weakness, in which to save his legs.

“These things happen” is the sentence families hear most often after a catastrophic hospital injury. Sometimes it is true. Finding out whether it is true in a particular case takes the complete record and physicians willing to give honest opinions about it, and neither of those is available to a family on its own.

How the Case Was Proved

The proof was in the nursing flowsheets, not the physician notes. Every page was obtained from both hospitals, the transport service, and every facility and physician that treated him afterward. What mattered was not the physician narratives. It was the hour by hour nursing record of deteriorating leg strength, sitting in the same chart the physicians were writing in and apparently never reading.

The transfer conversation itself was recovered. Hospital to hospital transfers are usually arranged through transfer centers, and those calls are frequently recorded. The firm obtained the audio and listened to what was actually said as the patient was handed from one institution to the next, and, more to the point, what was never said. In a failure of communication case, a contemporaneous recording of the communication is the evidence.

An emergency medicine expert addressed the transfer. His opinion was that the sending emergency physician fell below the standard of care by failing to tell the receiving hospital that the CT had been read as suggestive of vertebral osteomyelitis and discitis, and by failing to ensure the images and report went with the patient. He framed the consequence as an increased risk of a delayed diagnosis of epidural abscess and of permanent neurological injury.

A hospital medicine expert, who practices the same inpatient specialty as the defendants, addressed the two days on the floor. His findings were notable mainly for how basic they were. The admission note contained no review of systems for weakness or sensory loss, even though nursing had charted leg weakness on arrival and the operating neurosurgeon would later record that the patient described progressive weakening dating back to admission. Escalating narcotic requirements in a patient with a known destructive spinal lesion is a recognized warning sign of cord compromise, and the response was more narcotics rather than urgent imaging. No neurosurgeon was consulted for two days despite a known invasive lesion in the spine. And spinal cord compression never appeared on either physician’s differential, so it was never ruled out, because it was never considered.

His conclusion was that acute cord compression is a neurological emergency in which time to decompression determines the outcome, and that if anyone had examined this man’s legs, considered the diagnosis, and ordered the MRI urgently, the paralysis was avoidable.

The defense argument was anticipated. The defense retained its own emergency medicine expert, who opined that the emergency care met the standard, that the patient was neurologically intact when he left the first hospital, and that responsibility passed to the receiving hospital on transfer. That is precisely why the transfer center recordings, the nursing flowsheets, and a hospitalist expert who could walk a jury through what the receiving physicians failed to do with the patient physically in front of them mattered as much as they did.

What the Injury Costs

He completed a long course of IV antibiotics and was discharged not to his home but to a skilled nursing facility. Over the following year he was hospitalized repeatedly, and he developed pressure wounds, including one that extended to bone.

He is now a complete paraplegic at an upper thoracic level, with no motor function and no sensation below the chest. A neurogenic bladder means an indwelling catheter, and a neurogenic bowel means incontinence regardless of any bowel program.

A physiatrist, meaning a physician specializing in physical medicine and rehabilitation, examined him and made one finding that mattered enormously to the claim. With proper care, this patient has a nearly normal life expectancy. His damages could not be discounted as short term. Life care planning nurses then translated that opinion into an itemized, line by line projection of every element of care he will need for the rest of his life, supported by the treating and examining physicians rather than estimated.

Resolution

The matter was resolved confidentially and the terms are not disclosed here.

What can be said is how the resolution was built. Not on sympathy. It was built on a complete record showing that a hospital had a chart documenting deteriorating leg strength for two days and never examined the legs, on contemporaneous evidence of what was and was not communicated at transfer, on physicians in the defendants’ own specialties willing to say plainly what should have happened, and on a documented projection of what this injury will actually require.

What This Case Teaches

Nothing that went wrong here required a failure of medical brilliance. It was a failure of basics.

Information has to travel with the patient. A transfer is a handoff, not a discharge. When a scan raises infection, the receiving team has to hear the word infection. Images and reports should go with the patient or reach the receiving clinician before the patient does, and the sending physician should confirm the differential was actually communicated to a human being on the other end.

You have to examine the patient. Recording that someone is awake and oriented is not a neurological examination in a person with a lesion pressing on the thoracic cord. Strength, graded and by muscle group. Sensation, by level. Reflexes. Every shift, documented every time.

You have to read your own chart. Nursing documented weakness on the night of admission and tracked it worsening hour by hour, in the same record the physicians were writing in.

Escalating pain in a known spinal lesion is a red flag, not a dosing problem. More opioid is not a differential diagnosis. Pain that keeps outrunning the medication in a patient with a destructive spinal lesion is a reason to image the spine urgently.

Anchoring is dangerous. Once the receiving team accepted the framing that this was a tumor, every later finding got interpreted through that frame, and the alternative sitting on the radiologist’s own differential, the one that was treatable and time critical, was never revisited.

If This Happened to Someone You Love

If a family member walked into a hospital and left it paralyzed, or if a spinal infection, an epidural abscess, or cord compression was diagnosed only after the damage was permanent, you are entitled to more than “these things happen.”

Lupetin & Unatin, LLC handles catastrophic medical malpractice cases in Pennsylvania, including failure to diagnose spinal epidural abscess, delayed diagnosis of spinal cord compression, negligent hospital transfers and handoffs, emergency department negligence, and hospital medicine errors.

In cases like this one, that means obtaining the complete record, including the material hospitals do not volunteer, and reading the nursing documentation as closely as the physician notes. It means retaining physicians in the specialties at issue, so a hospitalist’s conduct is evaluated by a hospitalist. And it means developing the future cost of care through qualified life care planning, so any resolution is measured against a documented projection rather than an estimate.

Consultations are free and confidential. We handle these cases on a contingency fee basis, meaning our fee is a percentage of any recovery and no fee is owed if there is no recovery. Clients may remain responsible for case costs and expenses, and we explain in writing how costs are handled before you decide anything. If you are wondering whether what happened was preventable, no one can tell you without the records.