Delay in Diagnosis of Spinal Abscess: $1.1M Settlement
2015 Medical Malpractice Trial Report
Paralysis and a neurogenic bladder and bowel follow delay in diagnosis of spinal epidural abcess
On 6/27/14, at the age of 40, the plaintiff suffered bilateral lower extremity paralysis and a neurogenic bowel and bladder as a result of the failure to timely diagnose and treat a thoracic spinal epidural abscess.
On 6/22/14, the plaintiff presented to the Emergency Department with complaints of 10/10 neck and left shoulder pain and tightness for one week. She was evaluated by a nurse practitioner who diagnosed her with a muscle strain. She was discharged to home with prescriptions for pain medications.
On 6/26/14, the plaintiff again presented to the same Emergency Department. She complained of 10/10 upper back pain, neck pain, bilateral numbness in her lateral thighs. She reported that her symptoms had worsened since her visit four days prior, and the pain medication prescribed at that visit gave her no relief.
The defendant emergency medicine physician examined the plaintiff and noted mild tenderness at C4-T4, and decreased sensation to touch on bilateral thighs. There is no documentation of reflexes, rectal examination or sensation of the perineum or the trunk. The plaintiff underwent imaging studies including thoracic spine CT which revealed no acute fracture or subluxation. Laboratory blood testing revealed a high white blood cell count at 13.8. The defendant diagnosed the plaintiff with bilateral leg numbness of unclear etiology, and neck and upper back pain of unknown etiology. The plaintiff was discharged to home with pain medications.
About 15 hours after she was discharged, the plaintiff returned to the Emergency Department via ambulance. She reported lower extremity weakness, numbness, and urinary incontinence. She was unable to walk. Upon arrival, the plaintiff underwent a MRI of her entire spine, which revealed an epidural collection in the thoracic spine from T1 to the T5 level resulting in compression of the central cord. The overall findings were concerning for epidural abscess with extension into the interspinous soft tissues.
The plaintiff underwent an emergent T1-T5 laminectomy for epidural abscess evacuation. She now suffers from paraplegia and a neurogenic bowel and bladder.
The plaintiff claimed the defendant failed to recognize and appreciate the signs and symptoms of a spinal epidural abscess, including severe back pain, numbness or loss of sensation in the lower extremities, and a high white blood cell count, failed to immediately order and/or perform diagnostic testing, specifically an MRI, and failed to seek neurosurgical consultation and/or intervention. These failures resulted in the plaintiff suffering paraplegia and a neurogenic bowel and bladder.
The case was settled on a c. 231, section 60L demand letter for the full policy limits of the physician and hospital which had charitable immunity status.
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