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Were either of these physicians negligent?
Case Analysis by Brady Pregerson, MD
This case settled for a (large) undisclosed amount. Although there were a few other potentially confounding symptoms, this patient initially presented to the ED with bilateral arm numbness and bilateral leg weakness. These symptoms suggest spinal cord pathology, specifically cord pathology in the cervical region. The intrascapular pain that he had had for months seems to have been ignored on the first visit. Intrascapular pain can be caused by a muscle strain or rarely by aortic dissection, but is also frequently caused by cervical radiculopathy, which can precede or occur with myelopathy (disease of the spinal cord). In addition to bilateral arm or leg weakness or numbness, other symptoms that suggest myelopathy include ataxia, voiding difficulty or electric pain from coughing, sneezing or straining. Signs on physical exam that suggest myelopathy include bilateral limb numbness, especially if there is a sensory lever, bilateral limb weakness, a positive Hoffman’s sign or a wide based gait (due to loss of position sense from compression of the posterior columns).
When cord pathology is suggested, as in this case, the test of choice is a spinal MRI, or if not available, a spinal CT scan. Plain films may be considered when there is only radiculopathy and the patient will be referred, but are inadequate to rule out cord compression, which is a potential surgical emergency.
The main physician error during the initial ED visit was the choice of testing. As previously mentioned, plain films of the spine are inadequate for the evaluation of cord compression. A cervical MRI or CT was indicated, and should have been performed urgently. The fact that the plain films showed evidence of degenerative disc disease, combined with symptoms concerning for cord compression beg for advanced imaging of the neck. Instead, a CT of the brain was ordered – this despite the fact that there was really nothing in the history or exam that suggested cerebral pathology. When stroke causes weakness, it is almost always unilateral, not bilateral. A pontine stroke is one notable exception, but is quite rare. Based on the analysis above, my opinion is that the care at the initial ED visit was not reasonable. It was negligent.
At the second ED visit, which occurred about one month later, the patient’s symptoms were similar to the first visit, with the addition of shooting pain with neck flexion. This phenomenon is also known as Lhermitte’s sign and is another clue to myelopathy in the neck. The physical exam documentation on this visit was somewhat limited, with the neurologic examination summed up with one short phrase, “The patient is alert and oriented with no focal weakness or deficits”, that leaves one wondering what examination was actually performed. A head CT, still the wrong test, was again performed and was again normal. A chest x-ray was done, presumably to check for a source or intrascapular pain. No cross-sectional spinal imaging was ordered. Basically, on the second visit the presentation again strongly points to cervical myelopathy as the cause of the patient’s symptoms, even more so than on the first visit because Lhermitte’s sign is present (see sidebar for more details). Because no imaging was done to evaluate the spinal cord, my opinion is that on this visit as well, care was not reasonable.
There are a number of lessons to be emphasized from this case. First, it has been said that a good history is 85% of arriving at the correct diagnosis. This patient’s history was concerning for cord compression: symptoms in both arms point to this, as do symptoms in both legs, as does the electric shock feeling with neck flexion. Second, intrascapular pain is often a symptom of a myelopathy or a radiculopathy (C8 to be specific). Third, triggers that can aggravate pain related to cord disease include Valsalva, coughing, sneezing and/or neck flexion. Another trigger that I have encountered is yawning or jaw protrusion. Fourth, it is crucial to order the correct imaging test and not be falsely reassured by inadequate tests that return with normal results.
Twelve hours after the second ED visit the patient returned to the same ED by ambulance for bilateral leg paralysis and anesthesia associated with 10/10 pain between the shoulder blades and in both arms. Physical examination documented absent reflexes and strength in both legs but normal reflexes and strength in both arms. An MRI of the entire spine showed a large disc extrusion at C6-7 with superior migration and severe spinal stenosis with associated cord edema. The patient was taken emergently to the OR for discectomy and fusion. His final outcome after rehabilitation was complete motor and sensory C8 quadriplegia associated with neurogenic bowel and bladder dysfunction.
Case Analysis by William Sullivan, DO, JD
Determining the etiology for paresthesias is often challenging. The differential diagnosis for paresthesias is extensive and includes metabolic issues such as diabetes or hypoparathyroidism, toxic exposures such as alcohol and industrial solvents, autoimmune diseases such as multiple sclerosis and systemic lupus, medications including significant numbers of antihypertensives and antibiotics, withdrawal from chronic benzodiazepine or chronic antidepressant use, vascular issues such as Raynauds Disease and vasculitis, infections such as Lyme Disease or HIV, trauma or external compression of the nerves, vitamin deficiencies, migraine headaches, and paraneoplastic disorders. A small subset of patients has a hereditary etiology for their paresthesias. A thorough history and physical examination may exclude some causes of paresthesias, but in many cases the exact cause for a patient’s paresthesias may not be uncovered in the emergency department.
In this case, the patient’s lack of headache, trauma, fever, or medication use may reasonably exclude several potential etiologies for the patient’s paresthesias. The patient’s leg weakness may also have helped guide testing. While paresthesias plus leg weakness may suggest cervical cord impingement, even those symptoms are not entirely specific to cord compression. They can also be seen in multiple sclerosis and several other demyelinating diseases, amyloidosis, TIAs, and even severe vitamin B12 deficiency. Workup of many of these conditions is outside the scope of emergency medicine practice. The patient’s physical examination showed that he had normal sensation and normal leg strength, initial radiographic studies (although perhaps not the optimal tests) showed no concerning findings, and the patient was given appropriate follow up with a neurologist. Outpatient follow up seems reasonable in this case. However, the patient also complained of interscapular pain. Should this pain have prompted a better evaluation of the patient’s cervical spine on the patient’s first emergency department visit? Possibly. After all, interscapular pain is a known symptom of cervical radiculopathy. I must confess that the only reason I am aware of the association between cervical nerve root compression and interscapular pain is because I suffered from interscapular pain for more than a month before discovering that I had a cervical nerve root compression. Massages, stretching, and trigger point injections helped to some degree and I assumed that the pain was musculoskeletal. It wasn’t until I developed paresthesias in my middle finger and had an abnormal cervical MRI that a neurosurgeon informed me of the association. In my anecdotal discussions with colleagues about my experiences, I have found that many emergency physicians are not aware of the association between cervical nerve root compression and intrascapular pain.
During this patient’s first emergency department visit, I don’t think that the patient’s history and physical examination suggested an imminent emergency medical condition – a point bolstered (in retrospect) by the fact that the patient had no adverse outcome for more than a month after being discharged. Even though the patient had symptoms that suggested the possibility of cervical cord impingement, it isn’t unreasonable to recommend outpatient testing and follow up in patients without abnormal physical findings. We don’t obtain emergent MRIs of the lumbar spine in every patient with lumbar radicular pain and subjective leg weakness, nor do we jump to an MRI in every patient with knee injury – even if an effusion and ligamentous instability are present. The patient’s care may not have been exceptional during this first visit, but I believe it was reasonable.
A month later, the patient’s second visit showed a progression of symptoms. He described difficulty walking and exhibited Lhermitte’s phenomenon – shooting pain to the extremities when the neck is flexed. The patient was also visiting a chiropractor regularly during this timeframe raising the possibility a traumatic exacerbation of his symptoms due to spinal manipulation. Unfortunately, the documented physical examination seemed inadequate for a patient presenting with so many neurologic complaints. I agree with Brady on this point. Merely stating that a patient has “no focal weakness or deficits” leaves doubts about the extent of the neurologic examination that was performed. The patient complained of continued paresthesias, shooting pain to the extremities and difficulty walking in addition to the persistent thoracic pain. There was no specific documentation of sensory testing, strength testing, or gait testing. Retrospectively, it is also difficult to reconcile that a patient with progression of symptoms over six weeks had no focal weakness or deficits during this second visit, only to return twelve hours later with paralysis and complete absence of reflexes. The combination of progressive paresthesias to the extremities, difficulty walking, Lhermitte’s phenomenon, and interscapular pain suggest a cervical cord compression and progression of symptoms would be an indication for advanced imaging of the patient’s spine. Concerns over the persistence and progression of the patient’s neurologic complaints also could have been addressed by even a telephone consult with a neurologist. Such a consult would likely have led to further testing and would likely have prevented the patient’s injuries.
There are a few take-home points from this case. First, the law requires only that physicians provide “reasonable” medical care. While the legal definitions of “reasonable” differs between states, in general, those definitions describe what an “average” doctor would do, not what the “best” doctor would do. It is easy to decide what testing should have been done once a diagnosis is known, but consider this patient’s first visit without knowing the complaints in the second visit. Should an emergency MRI of the spine be performed on every patient with paresthesias, subjective leg weakness, interscapular pain and normal physical findings?
One of my mentors once told me that “four eyes are better than two.” Emergency physicians can’t be expected to recognize the nuances in every medical specialty. However, if a patient’s symptoms don’t make sense or the patient’s physical findings are confusing, consulting a colleague may help find a cause for a patient’s symptoms – or at least narrow the potential differential diagnosis. You may not know all the causes of paresthesias, may not recognize Lhermitte’s phenomenon, or may not know where low cervical radiculopathies radiate pain, but a specialist might. Don’t be afraid to ask for another opinion.
Finally, it is a good practice to address a patient’s complaints during a patient’s physical examination. It isn’t negligent to omit documentation of specific physical examination findings, but doing so will make it much more difficult to persuade a jury that you performed the exam in the event of a bad outcome. Although complaints such as malaise or nausea may be difficult to address on physical examination, complaints of a rash should have a corresponding skin exam and complaints of wrist pain should include an examination of the wrist. Note how documentation in the first visit specifically addressed many of the patient’s complaints while documentation during the second visit did not. If patient presents with paresthesias, documentation of a sensory exam shows that the issue was addressed. Documentation of muscle strength and gait testing show that complaints of weakness and difficulty walking have been addressed. Documentation of palpatory findings and range of motion testing may suggest that a patient’s upper thoracic pain is simply a muscle strain. Or, if you’re a sharp clinician, it may be that one piece of the puzzle that helps you diagnose a cervical cord compression before it is too late.
“The initial visit was fine. The physical exam on the second visit was inadequate. Here’s a golden opportunity to help someone who has returned for the same complaint. I’d have CT’d his neck and if that was normal, his thoracic spine. If both were normal, I’d have called neurology or neurosurgery and had him admitted.”
“Repeat visit warrants thorough well documented exam and telephone consultation with neurologist and document the conversation. Pt needs MRI of entire spine urgently but not emergently. He likely has a spinal cord mass. Second EP did not provide adequate care.”
“Not reasonable practice because no mention made of MRI which seems clearly indicated at time of first visit, let alone 2nd visit.”
“I would be concerned that his symptoms may be related to epidural abscess or a space occupying mass. MRI?”
“Progressive neurologic dysfunction with escalating severity of symptoms warrants spinal imaging beyond bony: CT with contrast or MRI of cervical spine: mass v. discitis v. epidural abscess.”
“I would have done a CT and maybe a spinal tap to rule out aneurysm or multiple sclerosis.”
“I think this is reasonable practice. He certainly has some sx that are worrisome for canal stenosis, but he has follow up arranged. I see no emergent reason for MRI but it should be done somewhat urgently as an outpatient.”
“I think this was reasonable practice as no focal neurologic deficits were present, especially functional deficits such as motor weakness. If the patient did not have a neurology appointment within 2 days already arranged by the 2nd visit, I would have felt that needed to be arranged to ensure follow up. The patient definitely needed a neurologist’s opinion and further work up. However, this could be reasonably obtained via an urgent outpatient visit as there were no neurologic exam findings and the patient was non-toxic nearly 1 month after the initial complaint.”
“Clear neuro deterioration. The workup was not adequate to assess cord or spinal nerve issues nor document any vascular problems, and does not suggest broad ddx.”