Date: October 20, 2023
Reference: Cai et al. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. AEM October 2023.
Guest Skeptic: Dr. Kirsty Challen is a Consultant in Emergency Medicine at Lancashire Teaching Hospitals.
Case: You are in your group meeting and have heard about a case at a nearby emergency department (ED) where the diagnosis of a spinal epidural abscess was delayed, and a substantial settlement has been made out of court. Your group director is concerned with avoiding the same thing happening in your department and wants to know if you should implement an evidence-based clinical management tool (CMT) to reduce delays in diagnosis.
Background: Spinal epidural abscess (SEA) is a diagnosis which can seem easy to make in retrospect. The majority of time (55%) the diagnosis of SEA often involves an error with a median length of time to diagnosis of 12 days according to one study [1]. Diagnostic delays were found to be present in 75% of SEA patients with only a minority (10-15%) of patients present with the “classic triad” of fever, back pain and neurologic deficit [2]. Another study reported that the 90% of patients misdiagnosed on their first ED visit [3] likely due to the non-specific and variable initial presentation, and the number of patients with back pain of benign origin seen in EDs [4].
SEA is the condition with proportionately the highest misdiagnosis rate in ED per a recent systematic review, and long-term sequelae for patients with associated medico-legal costs are high [5]. However, there is a need for clinicians to not let SEA become the next pulmonary embolism with high rates of over investigation.
We’ve looked at back pain on the SGEM before, mostly in terms of treatments. SGEM#366 concluded that we could not recommend the routine use of skeletal muscle relaxants, SGEM#304 agreed that adding acetaminophen to ibuprofen did not improve one-week outcomes, while SGEM#173 concluded the same about diazepam (there’s a theme here!).
We’ve also looked at the rational use of imaging on SGEM#283 (the Ottawa subarachnoid haemorrhage rule is highly sensitive but has very poor specificity). In SGEM#181, we were unconvinced of the value of routine use of whole body CT in trauma patients, and right back in 2015 on SGEM#106 discussing the Canadian CT head rule and the New Orleans Criteria. However, we’ve not previously looked at the intersection of non-traumatic back pain and rational investigation.
CLINICAL QUESTION: DOES IMPLEMENTATION OF A CLINICAL MANAGEMENT TOOL IMPROVE TIME TO DIAGNOSIS AND CHANGE TESTING RATES FOR SPINAL EPIDURAL ABSCESS?
Reference: Cai et al. Implementation of a Clinical Management Tool for Spinal Epidural Abscess Early Diagnosis. AEM October 2023.
Population: Adults attending at continuously-staffed EDs in a health network covering 15 states, 2016-19.
Excluded: Facilities not collecting radiology or lab order data, facilities without 6 months of data before and after intervention.
Intervention: Implementation of a literature-based Clinical Management Tool (CMT).
Comparison: Periods before and during the implementation of the CMT.
Outcomes:
Primary Outcome(s): 1. The proportion of patients with SEA with a potentially related visit in the previous 30 days and 2. For those with a prior visit, number of days from first visit to diagnosis.
Secondary Outcomes: Utilization rates for CT, MRI, Xray, ESR and CRP.
Type of Study: Implementation study.
Dr. Anglea Cai
This is an SGEM HOP and we are pleased to have the lead author on the show, Dr. Angela Cai. She is a Clinical Assistant Professor of Emergency Medicine at the University of Pennsylvania. She completed this work during her Innovation Fellowship at US Acute Care Solutions. Prior to that she trained at Kings County EM Residency in Brooklyn and the University of North Carolina Chapel Hill for her medical and business degrees.
The Skeptics Guide to Emergency Medicine 