Spinal Abscess Diagnostic Delay: $1.7M Settlement

Failure to order imaging of IV drug user with back pain leads to delay in diagnosis of spinal abscess

2023 Medical Malpractice Settlement Report
By Adam R. Satin, Attorney for plaintiff

Case summary

Plaintiff had a medical history of IV drug abuse, obesity and disc disease with sciatica. He presented to the emergency department on 12/8/14 with complaints of thoracic back pain radiating to his arm and described the pain as stabbing with an intensity of 10/10. He admitted to using intravenous heroin and fresh track marks were observed. Physical examination revealed bilateral tenderness in his lower thoracic region. His wbc was elevated at 12.0. The defendant emergency room providers felt it was most likely muscle-related but ordered tests to rule out a pulmonary embolism and gave pain medicine. Lung testing was negative and he was sent home without imaging with instructions to follow up with his PCP.

The plaintiff followed up as instructed to his PCP on 12/11/14 with continued symptoms. His PCP did not take his temperature, nor did he perform a rectal exam to check for abnormal rectal tone, nor did he order bloodwork that included an ESR and a serum C-reactive protein. The defendant PCP felt his symptoms were consistent with Shingles even though he had no rash.

The plaintiff returned the ER two days later on 12/13/14 with continued complaints of back pain. He reported that his PCP had told him it was Shingles and he also admitted to using heroin, but that even heroin did not relieve his pain. The defendant emergency room providers disagreed with the PCP’s diagnosis of Shingles as a cause and recommended he return to his PCP for a pain management referral and discharged him without imaging.

Just 14 hours after discharge from the ER, he returned to a different ER at 6:15am the next morning, complaining of 10/10 pain in his lower back and an inability to move his legs. He had been found lying on his bedroom floor reporting that his legs gave out around midnight and he was unable to move his legs and get up. Still, the defendants that morning failed to get him imaging in a timely manner. He was eventually transferred and imaging found a spinal abscess.

Plaintiff focused on the combination of the hallmark risk factor for a spinal abscess (IV drug use) along with the persistent and consistent symptoms that no defendant took the time to evaluate. The defense focused on the more common and more likely diagnoses for the plaintiff’s symptoms and suggested that the outcome would not have been altered with different care.

The case settled for $1,700,000.

Lubin & Meyer medical malpractice attorneys Andrew C. Meyer, Jr. and Adam R. Satin represented the plaintiff in this case.

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