Medical Malpractice Insights: Ankylosing Spondylitis and Trauma

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Ankylosing Spondylitis and Trauma

Elevate your index of suspicion for spinal injury 

Facts: A 42-year-old software engineer with a 10 year history of ankylosing spondylitis (AS) falls out of bed at home. He experiences severe pain in his back and abdomen and the next day presents to the ED. He informs the ED physician of his AS and expresses concern that he has a broken back. The ED physician orders an abdominal (?lumbar) CT scan that is unremarkable, but in hindsight shows an unstable hairline fracture in the lower thoracic spine. He is discharged with pain medication and follow-up instructions. The ED physician’s report is not entered into the EHR for 5 days. During the next 24 hours he returns to the ED twice with persistent pain, each time reporting his AS. On one visit, admission for pain control is advised by the ED physician, but a consulting hospitalist appears to focus attention on the earlier (erroneously negative) CT scan and discharges him from the ED. Two weeks later, still in pain, he returns a 4th time with incontinence of stool with tingling from his waist into his legs. A thoraco-lumbar MRI is ordered. During the procedure he experiences severe pain while being positioned and loses all function below his abdomen. The MRI confirms a T8/9 spinal fracture with cord compression. He is transferred to a tertiary center for further care and a lawsuit is filed.

Plaintiff: I told you I had AS and a broken back. You missed the fracture on the original CT scan. The CT scan should have included the thoracic spine because the fracture would have been found. You worsened my neurological problem during my MRI – which should have been done earlier, before I had any neurological symptoms. You should have warned the MRI technician about my brittle spine. Now I’m paralyzed and in a wheelchair for the rest of my life. I need daily nursing care and can’t drive. Your systems do not support adequate communication amongst caregivers. I don’t want this to happen to anyone else, so I won’t agree to a confidential settlement because everyone needs to learn from this.

Defense: Information on this case was obtained from newspaper reports. No defense position is available, but the resulting settlement speaks for itself.

Result: $20 million pre-trial settlement. Plaintiff requested 2 specific conditions as a part of the settlement:

1. the learnings from the case be made public in order to improve patient safety and
2. that he participate on the hospital’s process improvement team.

Takeaways:

• The hospital improved communication and handoffs by using alerts in the EHR, added a second layer of radiology reviews, and changed processes to review challenging cases.
• Patients with AS are at high risk for spinal injury, even from minor trauma.
• Elderly patients are particularly susceptible to cervical fractures, but AS patients are at even higher risk.
• Maintain a high index of suspicion in any AS patient with spine pain.
• Image liberally in AS patients.
• Repeat visits, aka “bouncebacks,” especially for back pain, require a careful re-assessment. (Spinal epidural abscess remains the #1 rule out; a CRP/ESR will do that over 99% of the time.)
• Assure that records of earlier visits are timely available to subsequent providers.

Reference: Ankylosing Spondylitis and Spinal Cord Injury. Jacobs et al., Medscape eMedicine www.medscape.com/viewarticle/570737_1