Epidural abscess

The member arranged to treat the coccydynia with manipulation under anaesthetic and a steroid injection into the para-coccygeal area and the sacro-coccygeal junction.

Some 12 days later, the patient was showing only minimal response to the treatment but otherwise appeared well. About a week later, though, he began to develop the symptoms of infection – headache, tremors and fever. He also complained of altered sensation below the waist and had difficulty passing urine. His wife contacted the surgeon, and he was assessed that day.

An urgent lumbar MRI and blood tests showed that the patient had a diffuse epidural infection throughout the lumbar spine, with epidural gas at L3, and pre- and post-sacral abscesses. The surgeon concluded that the patient had a serious spinal infection, the main site of which was the sacrococcygeal area.

The patient was immediately started on highdose IV antibiotics and the post-sacral abscess was aspirated percutaneously by a radiologist to drain the pus and identify the infection. Only 1ml of foul pus was obtained. The surgeon decided against surgery to drain the epidural abscess at that stage because the patient had no significant neurological deficit on examination and the MRI showed no evidence of neural compression.

For the next 24 hours, the surgeon continued to treat the patient conservatively under close observation. On examination the next day, the patient felt better and had passed urine, and the surgeon found no evidence of neurological deficit. A second MRI scan of the cervical and thoracic spine was requested because the first had shown infection up to L1 (the upper limit of that scan), showing that epidural infection extended to T10/T11. There was also enhancement of the meninges between T9 and L1.

He transferred the patient to the local NHS hospital, where he carried out excision and drainage of the sacro-coccygeal abscess that evening. A large abscess cavity was found posterior to the sacrum with evidence of necrotising faciitis. All infected and necrotic tissue was removed and the wound was left open.

Unfortunately, the patient's condition deteriorated steadily over the next three days, culminating in acute respiratory distress syndrome and intubation and ventilation in ITU. As his neurological condition could no longer be monitored properly and accurately the member took him back to theatre to drain the epidural abscess via lumbar fenestrations.

A small quantity of pus was found at L5/S1. This was not under pressure or causing any neurological compression and the epidural space was lavaged. There was no evidence of any purulent material further up the lumbar spine.

The severe sepsis kept the patient in hospital for the next three months. He recovered well but alleged that he was left with foot drop, altered sensation in the legs and sacral area and sexual dysfunction.

The patient brought a claim against the orthopaedic surgeon and the NHS hospital trust. His allegations were that the surgeon had failed to properly obtain the patient's consent to the procedure (although this was subsequently dropped) and failure to carry out extensive drainage and debridement of the whole epidural abscess when the patient first returned to hospital. It was also alleged that the Trust should have started different intravenous antibiotics (also dropped) and that there was an ongoing failure to drain and debride the abscess.

Outcome

The case was heard in the High Court. The claimant alleged that it did not matter that other spinal surgeons would have done the same as the surgeon, as the defendants' experts said they would have done. He argued that it was illogical and irrational not to have conducted extensive spinal surgery, given the severity and extent of the infection and the known risks associated with delayed treatment.

However the judge rejected the claimant's case, preferring the defendant's expert evidence that as the claimant showed no clear adverse neurological signs at the time it was claimed surgery should have been carried out, the surgeon was not negligent in adopting a conservative approach, given that extensive surgery carries increased risk for the patient. He dismissed the claimant's allegations against both the surgeon and the Trust.

This page was correct at publication on 06/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.