Neurology Expert Opines on Failure to Investigate Spinal Injury

This case involves a middle-aged male patient with a past medical history of diabetes and hypertension who presented to his local emergency department complaining of total body weakness. A complete neurological examination was not performed despite the fact that the patient described being weak all over. The Emergency physician ordered a CT of the head and Cervical spine, both of which were read as negative for an acute process and the neurologist on-call was notified, however the neurologist did not see the patient. The patient’s symptoms grew worse overnight, and the neurologist finally saw the patient next morning. A subsequent MRI demonstrated a large herniated disk with significant edema in the corresponding cervical cord. Eventually, the patient developed permanent paralysis.

Question(s) For Expert Witness

1. What is your experience being consulted on patients with acute bilateral weakness in the emergency department?

2. How much time should elapse between when a neurologist is consulted to when he or she sees the patient with acute weakness in the ED?

Expert Witness Response E-036010

As an attending physician in our Neuroscience ICU, I frequently receive patients from the ED with acute or sub-acute progressive weakness. The differential is broad - an examination of extremity tone, power, deep tendon reflexes and sphincter tone/sensation can help distinguish between a structural cervical spinal cord lesion, transverse myelitis (for which a lumbar puncture might be indicated), or Guillain Barre Syndrome, to name a few. We care for these patients on a routine basis in our ICU, both prior to and after surgery if neurosurgical intervention is indicated. Our academic medical center protocol is that one of our residents, fellows or attending physicians see the patient --at a minimum --within two hours of their consultation and even sooner if the patient's symptoms suggest a neurosurgical or neurological emergency. Cervical cord compression is one of the neurological emergencies for which fast decompression can prevent permanent quadriparesis or quadriplegia. MRI of the cervical spinal cord and spinal canal is more sensitive than CT for a variety of cord lesions, including compression, edema, infarction or inflammatory myelitis.