Physician and patients factors associated with outcome of spinal epidural abscess related malpractice litigation

Let’s Be Honest: These Medical Malpractice Cases Were a Pain in the Back

Introduction: This series reviews three cases of back pain where a highly morbid diagnosis was missed by an emergency physician and subsequently successfully litigated. Case Report: We review the clinical entities of spinal epidural abscess and cauda equina syndrome, challenging diagnoses that can be easily missed and lead to patient harm if not treated promptly. Here we offer suggestions for recognizing these conditions quickly, performing an adequate history and exam, and using documentation to support decision-making. Conclusion: When confronted with an unfortunate medical outcome, maintaining honesty is of paramount importance in medical-legal environments.

A Clinical Prediction Tool for MRI in Emergency Department Patients with Spinal Infection

Introduction

Patients with pyogenic spinal Infection (PSI) are often not diagnosed at their initial presentation, and diagnostic delay is associated with increased morbidity and medical-legal risk. We derived a decision tool to estimate the risk of spinal infection and inform magnetic resonance imaging (MRI) decisions.

Methods

We conducted a two-part prospective observational cohort study that collected variables from spine pain patients over a six-year derivation phase. We fit a multivariable regression model with logistic coefficients rounded to the nearest integer and used them for variable weighting in the final risk score. This score, SIRCH (spine infection risk calculation heuristic), uses four clinical variables to predict PSI. We calculated the statistical performance, MRI utilization, and model fit in the derivation phase. In the second phase we used the same protocol but enrolled only confirmed cases of spinal infection to assess the sensitivity of our prediction tool.

Results

In the derivation phase, we evaluated 134 non-PSI and 40 PSI patients; median age in years was 55.5 (interquartile range [IQR] 38–70 and 51.5 (42–59), respectively. We identified four predictors for our risk score: historical risk factors; fever; progressive neurological deficit; and C-reactive protein (CRP) ≥ 50 milligrams per liter (mg/L). At a threshold SIRCH score of ≥ 3, the predictive model’s sensitivity, specificity, and positive predictive value were, respectively, as follows: 100% (95% confidence interval [CI], 100–100%); 56% (95% CI, 48–64%), and 40% (95% CI, 36–46%). The area under the receiver operator curve was 0.877 (95% CI, 0.829–0.925). The SIRCH score at a threshold of ≥ 3 would prompt significantly fewer MRIs compared to using an elevated CRP (only 99/174 MRIs compared to 144/174 MRIs, P <0.001). In the second phase (49 patient disease-only cohort), the sensitivities of the SIRCH score and CRP use (laboratory standard cut-off 3.5 mg/L) were 92% (95% CI, 84–98%), and 98% (95% CI, 94–100%), respectively.

Conclusion

The SIRCH score provides a sensitive estimate of spinal infection risk and prompts fewer MRIs than elevated CRP (cut-off 3.5 mg/L) or clinician suspicion.

Medical Malpractice Claims and Mitigation Strategies Following Spine Surgery

STUDY DESIGN

Narrative review.

OBJECTIVE

The aim of this narrative review is to examine trends in malpractice litigation arising from spine surgery. We also hope to detail mitigation strategies that surgeons can employ to decrease their risk of a claim.

METHODS

A review of the relevant literature examining the prevalence, risks, and outcomes of malpractice litigation following spine surgery was conducted using the MEDLINE and Embase databases.

RESULTS

Combined queries identified 1140 potentially relevant articles. After eliminating duplicate articles and screening by title and abstract, 38 articles underwent full-text review. Of these, 22 were deemed relevant to the research questions posed. Evaluation of references identified 1 additional relevant article. Spine surgery represents one of the most litigious specialties in the United States health care system. The available literature points to a consistent pattern of common allegations leading to litigation following spine surgery. While a majority of filed lawsuits end in the surgeon's favor, these cases carry high monetary and time expenditures regardless of outcome. Furthermore, the threat of a malpractice lawsuit motivates many surgeons to practice defensive medicine by utilizing unnecessary or unindicated tests and studies.

CONCLUSION

Through the examination of trends in malpractice claims and case outcomes, surgeons may be able to adapt practices to minimize their risk of litigation. These changes can include, but are not limited to, identification of those procedures that are most litigious and a more thorough discussion of the informed consent process to include operative and nonoperative treatments prior to all procedures. More important, however, spine surgeons can potentially serve as advocates for change.

Malpractice Litigation Involving Chiropractic Spinal Manipulation

OBJECTIVE

To evaluate the relationship between chiropractic spinal manipulation and medical malpractice using a legal database.

METHODS

The legal database VerdictSearch was queried using the terms "chiropractor" OR "spinal manipulation" under the classification of "Medical Malpractice" between 1988 and 2018. Cases with chiropractors as defendants were identified. Relevant medicolegal characteristics were obtained, including legal outcome (plaintiff/defense verdict, settlement), payment amount, nature of plaintiff claim, and type and location of alleged injury.

RESULTS

Forty-eight cases involving chiropractic management in the United States were reported. Of these, 93.8% (n = 45) featured allegations involving spinal manipulation. The defense (practitioner) was victorious in 70.8% (n = 34) of cases, with a plaintiff (patient) victory in 20.8% (n = 10) (mean payment $658,487 ± $697,045) and settlement in 8.3% (n = 4) (mean payment $596,667 ± $402,534). Overaggressive manipulation was the most frequent allegation (33.3%; 16 cases). A majority of cases alleged neurological injury of the spine as the reason for litigation (66.7%, 32 cases) with 87.5% (28/32) requiring surgery. C5-C6 disc herniation was the most frequently alleged injury (32.4%, 11/34, 83.3% requiring surgery) followed by C6-C7 herniation (26.5%, 9/34, 88.9% requiring surgery). Claims also alleged 7 cases of stroke (14.6%) and 2 rib fractures (4.2%) from manipulation therapy.

CONCLUSIONS

Litigation claims following chiropractic care predominately alleged neurological injury with consequent surgical management. Plaintiffs primarily alleged overaggressive treatment, though a majority of trials ended in defensive verdicts. Ongoing analysis of malpractice provides a unique lens through which to view this complicated topic.

Medical Malpractice and Trigeminal Neuralgia: An Analysis of 49 Cases

PURPOSE

Our study fills the vacancy of litigation research related to trigeminal neuralgia management, giving health care providers the information needed to understand the potential litigious outcomes that follow treatment methods.

METHODS

We queried the Westlaw database to identify litigation cases related to trigeminal neuralgia management. Key variables extracted included medical complaints, trial outcomes, and demographics. Continuous variables were compared between cases in favor of defendant and cases in favor of plaintiff using t-test or Wilcoxon rank sum test. Categorial variables were compared using χ² or Fisher exact test.

RESULTS

About 49 cases met the inclusion criteria-for those cases surgical complications (42.9%) were cited as the most common reasons for malpractice claims. Cranial nerve deficits (34.7%) were the most frequent postoperative complaints. Verdicts ruled in favor of the plaintiff in 26.5% of cases with a mean payout of $1,982,428.46. Dentists were included in the most cases, 63.3%, and the average payout was $415,908, whereas neurosurgeons were involved in 20.4% of cases with an average payout of $618,775. Cases with verdicts in favor of the plaintiff were more likely to be older than cases with verdicts in favor of the defendant (P = .03).

CONCLUSIONS

Over one-half of cases resulted in verdicts in favor of the defendant with surgical complications cited as the most common reason for litigation. Dentistry was the most common individual clinical specialty for defendants, whereas neurosurgery contributed to the largest average payout based on specialty (for n > 1). Cranial nerve deficits were the most common plaintiff postoperative complaints. These analyses may help doctor teams involved in management of trigeminal neuralgia to have a more informed discussion with the patient at every visit so that such litigations may be avoided.

Determinants of brain tumor malpractice litigation outcome and indemnity payments: a 29-year nationwide analysis

OBJECTIVE

Medical malpractice litigation is a significant challenge in neurosurgery, with more than 25% of a neurosurgeon’s career on average spent with an open malpractice claim. While earlier research has elucidated characteristics of litigation related to brain tumor treatment, factors impacting outcome and indemnity payment amount are incompletely understood.

METHODS

The authors identified all medical malpractice cases related to brain tumors from 1988 to 2017 in VerdictSearch, a database of 200,000 cases from all 50 states. The outcome for each case was dichotomized from the perspective of the defendant physician as favorable (defendant victory) or unfavorable (plaintiff victory or settlement). Indemnity payments were recorded for cases that resulted in settlement or plaintiff victory. Univariate regression was used to assess the association between case characteristics and case outcome as well as indemnity payment amount. Subsequently, significant variables were used to generate multivariate models for each outcome. Statistical significance was maintained at p < 0.05.

RESULTS

A total of 113 cases were analyzed, resulting most commonly in defendant (physician) victory (46.9%), followed by settlement and plaintiff victory (both 26.5%). The most common specialty of the primary defendant was neurosurgery (35.4%), and the most common allegation was improper diagnosis (59.3%). Indemnity payments totaled $191,621,392, with neurosurgical defendants accounting for $109,000,314 (56.9%). The average payments for cases with a plaintiff victory ($3,333,654) and for settlements ($3,051,832) did not significantly differ (p = 0.941). The highest rates of unfavorable outcomes were observed among radiologists (63.6%) and neurosurgeons (57.5%) (p = 0.042). On multivariate regression, severe disability was associated with a lower odds of favorable case outcome (OR 0.21, p = 0.023), while older plaintiff age (> 65 years) predicted higher odds of favorable outcome (OR 5.75, p = 0.047). For 60 cases resulting in indemnity payment, higher payments were associated on univariate analysis with neurosurgeon defendants (β-coefficient = 2.33, p = 0.017), whether the plaintiff underwent surgery (β-coefficient = 2.11, p = 0.012), and the plaintiff experiencing severe disability (β-coefficient = 4.30, p = 0.005). Following multivariate regression, only medical outcome was predictive of increased indemnity payments, including moderate disability (β-coefficient = 4.98, p = 0.007), severe disability (β-coefficient = 6.96, p = 0.001), and death (β-coefficient = 3.23, p = 0.027).

CONCLUSIONS

Neurosurgeons were the most common defendants for brain tumor malpractice litigation, averaging more than $3 million per claim paid. Older plaintiff age was associated with case outcome in favor of the physician. Additionally, medical outcome was predictive of both case outcome and indemnity payment amount.

Spinal Epidural Abscess: Diagnosis, Management, and Outcomes

An infection of the spinal epidural space, spinal epidural abscess (SEA) is a potentially devastating entity that is rising in incidence. Its insidious presentation, variable progression, and potential for precipitous neurologic decline make diagnosis and management of SEA challenging. Prompt diagnosis is key because treatment delay can lead to paralysis or death. Owing to the nonspecific symptoms and signs of SEA, misdiagnosis is alarmingly common. Risk factor assessment to determine the need for definitive MRI reduces diagnostic delays compared with relying on clinical or laboratory findings alone. Although decompression has long been considered the benchmark for SEA, considerable risk associated with spinal surgery is noted in an older cohort with multiple comorbidities. Nonoperative management may represent an alternative in select cases. Failure of nonoperative management is a feared outcome associated with motor deterioration and poor clinical outcomes. Recent studies have identified independent predictors of failure and residual neurologic dysfunction, recurrence, and mortality. Importantly, these studies provide tools that generate probabilities of these outcomes. Future directions of investigation should include external validation of existing algorithms through multi-institutional collaboration, prospective trials, and incorporation of powerful predictive statistics such as machine learning methods.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Risk Management and Avoiding Legal Pitfalls in the Emergency Treatment of High-Risk Orthopedic Injuries

Many orthopedic injuries can have hidden risks that result in increased liability for the emergency medicine practitioner. It is imperative that emergency medicine practitioners consider the diagnoses of compartment syndrome, high-pressure injury, spinal epidural abscess, and tendon lacerations in the right patient. Consideration of the diagnosis and prompt referrals can help to minimize the complications these patients often develop.