Missing The Big Picture

Case history

Mr A was a 42 year old man, who worked as a labourer. He had been attending a solo general practice for some 10 years. 

On May 16th 2004 he consulted his GP with the complaint of neck pain. He stated that he had been working with a jack hammer since the previous day and his neck had become sore. The GP’s notes were brief, but he recorded that Mr A was very tender around the neck and movement was painful. The GP prescribed Tramal and gave Mr A a medical certificate for 4 days off work.

Two days later Mr A presented again, complaining that his neck was not getting any better and the GP recorded ‘pain++’. His GP prescribed Valium on this occasion and extended Mr A’s time off work for another 3 days.

The following day June 19th, Mr A awoke and found that he was unable to move his arms or legs and he had no sensation below the nipple line. He called an ambulance and was taken to hospital. 

At hospital, Mr A underwent an MRI scan which showed a cervical epidural abscess. He underwent a laminectomy and drainage of the abscess followed by intravenous antibiotics. He had a rather stormy course in hospital and was eventually discharged some 87 days later, a complete quadriplegic at the C5 level.

He required assistance with all activities of daily living, including assistance with all transfers and assistance with bowel and bladder function. He was unable to return to his previous employment or to any employment at all.

Medico-legal issues

Two years later, Mr A commenced proceedings against his GP.

Initially it was thought that this case was defensible, when the two consultations in June 2004 were considered. Expert opinions were obtained from a number of general practitioners that the standard of care in these two consultations was appropriate and it was not unreasonable that the rare diagnosis of epidural abscess was not made. However it became apparent that there was a long lead up to these final presentations.

Mr A had been a patient of this GP for about 10 years. During this time, he had consulted his GP on about 100 occasions for a variety of ailments and injuries. During the early part of this ten year period, Mr A was prescribed antibiotics for infections at a rate of about once a year, which is consistent with common experience throughout Australia. Commencing about two years prior to the final presentation, Mr A began to experience far more frequent infections and consequently his attendances upon his GP for the prescriptions of antibiotics increased dramatically. During this two year period, the GP was consulted on about thirty occasions and twenty four of these were in relation to infections.

Most of these infections were skin infections. Some were boils and some were larger, more serious abscesses. Mr A required referral to a surgeon for formal drainage of large soft tissue abscesses on four occasions. Swabs were taken several times and on each occasion grew Staph. aureus. 

Expert opinion was that a competent general practitioner should have been alerted by this highly significant change in the number and nature of the plaintiff’s presentations to him. If the GP had considered this increase in infection he should have been aware of the more likely conditions that may give rise to an increased susceptibility to infections and should have arranged appropriate investigations or referrals. Swabs were taken on several occasions from the skin infections themselves and also from the patient’s nose. Staph. aureus was found in heavy concentration in the wound swabs and also in Mr A’s nose. The GP did not consider the possibility that Mr A was a chronic staphylococcus carrier and institute any further investigation, treatment or referral despite the frequent attendances with serious skin infections and the GP experts were critical of this.

The same surgeon was involved in the drainage of all of Mr A’s abscesses. Expert opinions were also critical of the surgeon in that he did not highlight the unusual nature of this presentation to the GP and suggest further management strategies such as more thorough microbiological investigations or referral to a specialist microbiologist or initiate such measures himself while the patient was directly under his care.

Unfortunately it was the general opinion of the experts that if Mr A had been referred to a specialist regarding his recurrent skin infections and received appropriate antistaphyloccal treatment, then he may not have developed the epidural abscess.

It is not uncommon for patients to be infected with a strain of S. aureus and for that strain to cause chronic colonisation of the body with repeated skin infections and other more serious infections from time to time. Unless such patients are treated aggressively to try to eradicate not just skin carriage, but also pharyngeal and gut carriage, then recurrences are common. A decontamination regimen would include topical antiseptics and a prolonged course of systemic antibiotics^1,2.

The matter was eventually settled for a large sum with a significant proportion from the GP and a smaller proportion from the general surgeon. 

Discussion and risk management strategies

GPs are uniquely placed to care for patients over a period of time and develop a relationship with them. They are also in a unique position to detect changes in the patient’s health, such as a marked increase in infection. GPs should consider both the presenting complaint and also the patient’s history and background.

Epidural abscess is an uncommon condition, but MDA National has received incidents and notifications of this condition as the diagnosis is often elusive and can result in devastating neurological damage. The percentage of patients achieving full recovery is between 41% and 47% with mortality at 16%. The incidence appears to be increasing and comprises up to 2/10,000 hospital admissions³. Spinal epidural abscess is more common in men and can occur at any age, although it is more common in the over 30 age group, with a peak incidence in the sixth decade. Risk factors include intravenous drug use, concomitant infections which are the source of haematogenous spread or direct extension, diabetes, malignancy, chronic renal disease, AIDS and steroid use. Epidural anaesthesia is also a risk factor, accounting for approximately 5% of cases.

The triad of fever, back pain and progressive neurologic deficit is the classic presentation, but not all patients have fever. Staphylococcus is the most common causative organism with an incidence of 60-80%. MRI is the investigation of choice. Treatment is urgent surgical decompression and appropriate intravenous antibiotics for 4-6 weeks.

The prognosis is dependent on the neurological condition of the patient at presentation. A high index of suspicion is required, particularly in those patients with predisposing risk factors. Early diagnosis and prompt treatment are essential to prevent serious morbidity and mortality.

References

1. Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y. A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection. Arch Intern Med. 1996 May 27;156(10):1109-12.
2. Therapeutic Guidelines Limited. Therapeutic guidelines : antibiotic. North Melbourne, Vic.: Therapeutic Guidelines Limited; 1998. p. v.
3. Curry WT, Jr., Hoh BL, Amin-Hanjani S, Eskandar EN. Spinal epidural abscess: clinical presentation, management and outcome. Surg Neurol. 2005 Apr;63(4):364-71; discussion 71.