Patient Suffers Quadriplegia After Delayed Infection Diagnosis

Case Summary

This case involves a female patient with a chief complaint of a large lump in the front of her neck. Multiple outpatient providers evaluated the mass. The patient initially received a diagnosis of a localized MRSA neck abscess.

A subsequent lumbar puncture revealed meningitis. An ENT surgeon performed surgical drainage of the abscess. A further pocket of infection, unfortunately, remained and continued to compromise the patient’s cervical spinal cord. The patient required a subsequent neurosurgical intervention. Ultimately, she suffered severe, permanent neurologic deficits, including quadriplegia (tetraplegia).

Case Theory

In the epidural space of the vertebral canal, a cervical abscess is a collection of pus-filled infectious material caused by a bacterial infection. Neurological sequelae can result from compression of nerve structures and the spinal cord itself at the condition’s peak.

Spinal meningitis infection is a medical emergency. In addition to causing brain damage, paralysis, and strokes, the infection left untreated can be fatal in some cases. Meningitis can have long-term health effects. The symptoms may include seizures and hearing loss. The complications associated with bacterial meningitis tend to be more severe than those associated with other forms of meningitis, such as viral.

Unless identified and treated early, the formation of an infectious collection within the spinal canal can quickly lead to permanent disability and death. It is imperative that physicians recognize spinal epidural abscesses even in the absence of traditional risk factors.

MRSA should be considered a potential pathogen in deep neck space abscesses. A high index of suspicion is prudent as well as aggressive treatment, including incision and drainage, along with culture-directed medical therapy. Surgical drainage may be the most important aspect of treatment. In this case, the failure to remove the secondary source of infection fell below the standard of care. The patient became paralyzed after a second cervical abscess site was neglected and spinal meningitis was not diagnosed in a timely manner.

Expert Witness Specialties

Neurosurgery

A neurosurgeon can speak to causes of paralysis, the complications of a cervical abscess, and the need to promptly diagnose and treat spinal meningitis to ensure the complete removal of infectious abscesses.

Questions for Expert Witness

• What are the standard diagnostic tests to evaluate a patient with a neck mass?
• How might a delay in the diagnosis of an epidural abscess impact a potential adverse outcome?
• What surgical measures are appropriate to ensure the removal of an abscess?
• When is the evaluation of CSF for Meningitis appropriate?
• What are the possible outcomes of allowing a pocket of infection to remain after surgery, and did the surgeon here fall below the standard of care?
• How does a delay in the diagnosis of bacterial meningitis affect a patient’s prognosis?

Expert Witness Involvement

Here is what the neurological surgery expert in this case had to say:

Expert Witness Response E-262638

I have extensive experience with treating patients with a spinal epidural abscess. Diagnostic tests include ultrasound and CT of the soft tissues. Given the LP diagnosis of meningitis and the known abscess in the neck, an MRI of the cervical and possibly thoracic spine with and without contrast would have been a standard diagnostic test, especially if the patient was having any additional neurological symptoms. A spinal epidural abscess can cause spinal cord injury with direct compression as the mass effect of the abscess increases. Also, the lumbar puncture could have exacerbated spinal cord injury if there was already cord compression and no room for CSF flow around that portion of the compressed cord. Earlier diagnosis and surgical decompression of spinal cord compression increase the chance of preventing severe neurological compromise and increases the chance of reversal of any active neurological symptoms.