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Original Contributions The Journal of Emergency Medicine, Vol. 26, No. 3, pp. 285Ϫ291, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/04 $–see front matter doi:10.1016/j.jemermed.2003.11.013 Original Contributions THE CLINICAL PRESENTATION AND IMPACT OF DIAGNOSTIC DELAYS ON EMERGENCY DEPARTMENT PATIENTS WITH SPINAL EPIDURAL ABSCESS Daniel P. Davis, MD,* Ruth M. Wold, MD,* Raj J. Patel, MD,* Ailinh J. Tran,† Rizwan N. Tokhi, MS4,† Theodore C. Chan, MD,* and Gary M. Vilke, MD* *Department of Emergency Medicine and †School of Medicine, University of California, San Diego, San Diego, California Reprint Address: Daniel Davis, MD, Department of Emergency Medicine, UCSD Medical Center, 200 West Arbor Drive, #8676, San Diego, CA 92103-8676 e Abstract—Previous reports have recommended the use delays (odds ratio 5.65, 95% C.I. 1.15–27.71, p < 0.05). The of a “classic triad” of fever, spine pain, and neurologic “classic triad” of spine pain, fever, and neurologic abnor- deficits to diagnose spinal epidural abscess (SEA); however, malities was present in 13% of SEA patients and 1% of the prognosis for complete recovery is poor once these controls during the initial visit (p < 0.01); one or more risk deficits are present. This retrospective case-control study factors were present in 98% of SEA patients and 21% of investigates the impact of diagnostic delays on outcome and controls (p < 0.01). The erythrocyte sedimentation rate explores the use of risk factor screening for early identifi- (ESR) was more sensitive and specific than total white cation of SEA in a population of ED patients. Inpatients blood cell (WBC) count as a screen for SEA. In conclusion, with a discharge diagnosis of SEA and a related ED visit diagnostic delays are common in patients with SEA, often before the admission were identified over a 10-year time leading to irreversible neurologic deficits. The use of risk period. In addition, a pool of ED patients presenting with a factor assessment is more sensitive than the use of the chief complaint of spine pain was generated; controls were classic diagnostic triad to screen ED patients with spine hand-matched 2:1 to each SEA patient based on age and pain for SEA. The ESR may be a useful screening test gender. Data regarding demographics, presence of risk fac- before magnetic resonance imaging in selected tors, physical examination findings, laboratory and radio- patients. © 2004 Elsevier Inc. graphic results, and clinical outcome were abstracted from medical records and entered into a database for further e Keywords—epidural abscess; spinal infection; cauda analysis. Patients with SEA were compared to matched equina; myelopathy; diagnosis controls with regard to the prevalence of risk factors and the “classic triad.” We also explored the impact on outcome of diagnostic delays, defined as either: 1) multiple ED visits INTRODUCTION before diagnosis, or 2) admission without a diagnosis of SEA and >24 h to a definitive study. A total of 63 SEA Spinal epidural abscess (SEA) is a relatively uncommon patients were hand-matched to 126 controls with spine but potentially devastating disease due to the high po- pain. Diagnostic delays were present in 75% of SEA pa- tential for permanent neurologic disability. Despite ad- tients. Residual motor weakness was present in 45% of vances in diagnostic imaging modalities, antibiotic ther- these patients vs. only 13% of patients without diagnostic apy, and surgical techniques, almost half of survivors are left with neurologic deficits, including 15% with paresis This work was presented at the ACEP Research Forum, Las or complete paralysis (1). The most critical factor in Vegas, 1999 and the ACEP Research Forum, Seattle, 2002. preventing permanent disability is early recognition and RECEIVED: 13 February 2003; FINAL SUBMISSION RECEIVED: 18 September 2003; ACCEPTED: 3 November 2003 285 286 D. P. Davis et al. treatment, as almost 90% of SEA patients are left with two controls from this pool using age and gender. Data residual weakness when motor deficits are present at the were collected in an identical manner for both the SEA time of diagnosis (1–3). Unfortunately, the early identi- cohort and the hand-matched controls. fication of SEA is difficult given its infrequency and the Data were abstracted from medical records onto a non-specific nature of early symptoms (1–8). Further- standardized form by one of four investigators. The first more, the definitive diagnosis is usually made using 15 charts were reviewed by all four to establish consis- magnetic resonance imaging (MRI) or computed tomo- tency with regard to data collection and to identify data gram (CT) myelography, both of which may be difficult points missing from the standardized abstraction form; to obtain on an emergent basis (1,9,10). Thus, the classic for the remainder of the charts, any questions regarding diagnostic triad of spine pain, fever, and neurologic abstracted data were referred to the principal investigator deficits, defined with the initial descriptions of SEA, is to maintain consistency. Data were ultimately entered still considered the hallmark of this disease (5,11,12). into an Excel௡ (Microsoft, Redmond, WA) spreadsheet This presents the Emergency Physician (EP) with a for further analysis. Collected data included: demograph- dilemma, as use of this “classic triad” relies on the ics, history of present illness (presenting complaints, presence of potentially irreversible neurologic deficits duration of symptoms, and number of ED and MD vis- (5). Although previous studies have documented initial its), past medical history with emphasis on a priori risk misdiagnoses in patients with SEA, there have been no factors, physical examination (vital signs, back examina- previous attempts to systematically investigate the early tion, and neurologic examination), post-void residual, presentation of this disease, the consequences of diag- laboratory results (CBC, ESR, blood and wound cul- nostic delays, or the use of alternative screening strate- tures), radiographic findings, hospital course, and neuro- gies to achieve earlier diagnosis (2,5–8,11). This retro- logic status at the time of discharge. Risk factors de- spective case-control study investigates the early scribed previously included: diabetes, intravenous drug presentation and impact of diagnostic delays on SEA and use, liver disease, renal failure, indwelling catheter, im- explores the use of risk factor assessment as a screening munocompromised status, recent invasive spinal proce- strategy in a population of Emergency Department (ED) dure, vertebral fracture, and distant site of infection patients presenting with spine pain. (2,4,8,12,13). The “classic triad” for SEA was defined as fever (temperature Ն 38°C, 100.4°F), spine pain, and a neurologic deficit documented during the ED visit. Data METHODS were abstracted from attending and house officer ED notes and the admission note written by the inpatient This was a retrospective case-control study conducted in service. A risk factor or neurologic abnormality was a large, urban university hospital with approximately considered present if it was included on any of the notes; 45,000 ED visits each year. Waiver of consent was the attending EP note was used with any inconsistencies granted by our Investigational Review Board. Patients in documented data. with SEA were identified from a computerized database Patients with SEA were compared to controls with maintained by our medical records department using regard to the prevalence of risk factors as defined above ICD-9 discharge codes (intra-spinal abscess, 324.1) over and the presence of the “classic triad” for SEA. The a 10-year period from April 1992 to March 2002. We sensitivity, specificity, positive and negative predictive also examined medical records of patients with a diag- value, and the likelihood ratios were also calculated. In nosis of vertebral osteomyelitis or discitis to screen for addition, SEA patients were stratified into those with and concurrent SEA. The final diagnosis of SEA was con- without a diagnostic delay, defined as either: 1) multiple firmed by operative reports or final MRI or CT interpre- ED visits without a diagnosis of SEA, or 2) admission to tations. Patients were excluded if they had not been seen the hospital without mention of SEA and greater than in the ED for symptoms related to SEA before the 24 h to a diagnostic study (inpatient delay), accounting hospitalization, although admission from the ED was not for patients admitted specifically to obtain a diagnostic required. Any ED evaluation subsequent to the onset of study on the following day. Due to the possibility that symptoms as defined by the patient was considered. Our septic embolization to the spine could occur during hos- primary interest was in the clinical presentation of bac- pitalization in a patient with endocarditis or a distant site terial epidural abscess. Thus, patients with fungal and of infection, signs or symptoms consistent with SEA tuberculous abscesses, who were anticipated to have a (spine pain, radicular pain, or neurologic deficits) were more indolent course, were excluded from this analysis. required during the ED visit for inclusion in the inpatient A pool of ED patients presenting with back or neck pain delay to diagnosis group. Elopement or discharge against was generated using our computerized ED medical medical advice with subsequent presentation to the ED record database. Each SEA patient was hand-matched to was not considered a diagnostic delay. For patients trans- Diagnostic Delays with SEA 287 Table 1. Sensitivity, Specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and Likelihood Ratios for a Positive (LR؉) and Negative (LR؊) Test for the Incidence of the “Classic Triad” Versus Risk Factor Assessment in Screening ED Patients with Spine Pain for SEA Sensitivity Specificity PPV NPV LRϩ LRϪ Classic triad 7.9 99.2 83.3 68.3 10.0 0.93 Risk factors 98.4 78.6 69.7 99.0 4.6 0.02 ferred from other facilities or admitted from clinic, a and 37% of patients, respectively.
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