The Case: Diagnosing Ankylosing Spondylitis

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a Peer-Review of Expert Witness Testimony
The Case
A patient with a history of alcoholism was brought to the emergency department by ambulance after falling five days earlier. After the fall, the patient experienced significant back pain and had been laying on a mattress in his basement. His physical examination was significant for superficial bed sores and back tenderness. His neurologic status was intact, although there is testimony that the patient developed increasing weakness in one leg before he left the ED. Spinal X-rays and CT showed fractures of the posterior body and posterior element of L1, the transverse processes of L2 and L3, and a fracture of T12 with moderate distraction of fracture fragments. The X-rays also showed findings consistent with ankylosing spondylitis.
The emergency physician contacted the on-call internist and the on-call orthopedist (a member of a group that had a spine specialist). The patient was admitted to the orthopedic floor with neurologic checks every two hours. Spinal precautions were not ordered.
When the patient arrived on the orthopedic floor, his neurologic status was described as being normal. On the orthopedic floor, the patient was reportedly not seen by either the admitting physician or the spine specialist for more than 24 hours. He developed signs consistent with alcohol withdrawal and was transferred to the telemetry floor. During the following 24 hours, the patient developed incontinence and was eventually rendered a paraplegic from spinal cord compression.
Expert Testimony:
 In excerpts from the expert witness deposition, John Flaherty, MD, an associate professor at Northwestern Medical School, testified that ankylosing spondylitis is “one of the first diseases that you study in medical school.” He went on to state the following:
–In 21 years of emergency medicine practice, he had seen 500 to 600 cases of ankylosing spondylitis and had been the diagnosing physician in approximately 150 to 200 of those cases.
–Spinal fractures occurring in ankylosing spondylitis are “almost always unstable,” represent an “extreme risk,” and “almost always lead to neurologic damage unless they’re attended to right away.”
–There is a “two to three times greater incidence of spinal cord compression” in ankylosing spondylitis patients suffering from spinal fractures and such statistics are “well described in medical textbooks and in the medical literature.”
–Spinal fractures in ankylosing spondylitis can be compared to acute myocardial infarctions in that they are “one of the few true emergencies we have.”
The expert faulted the emergency physician for:
–Failing to understand the pathophysiology of spinal fractures in patients with ankylosing spondylitis (which the expert also called “brittle spine disease”)
–Failing to have the patient either evaluated in the emergency department by a spinal surgeon or transferring the patient to a hospital where the patient could be immediately evaluated by a spinal surgeon
–Failing to admit the patient to the intensive care unit–Failing to perform a rectal exam on the patient
–Attributing weakness on the patient’s re-examination to a “pain response” instead of spinal cord injury
You be the judge
Do the expert’s statements represent the standard of care in emergency medicine regarding ankylosing spondylitis? Are his criticisms of the emergency physician’s actions justified?
Send your thoughts to editor@epmonthly.com. We’ll publish the verdict in the August print edition and online.
ABOUT THE AUTHOR

MANAGING EDITOR Logan has edited and designed Emergency Physicians Monthly since 2005. In 2010, Logan launched Emergency Physicians International, a new magazine and social network for global emergency care development. He is also the editor-in-chief of Telemedicine Magazine.

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