Overlooked Danger: The Missed Diagnosis of Spinal Hematoma

Introduction

This case study explores the delay in the diagnosis and treatment of the spinal hematoma that resulted in acute plegia, neurogenic bladder, and other functional impairments in a patient who presented with excruciating abdominal and back pain.

What They Needed

A leading law firm in Michigan sought to investigate whether there were any delays in the diagnosis and treatment of celiac artery dissection or spinal cord hemorrhage, which resulted in paralysis and chronic pain in the patient.

How We Did It

Medical Background

• The patient had a medical history significant for osteoarthritis, rheumatoid arthritis, varicose veins in bilateral lower extremities, and paroxysmal atrial fibrillation requiring anticoagulation (Xarelto).

• Recently, the patient was diagnosed with COVID-19 and a urinary tract infection with ongoing antibiotic treatment.
  

Correlation of Symptoms and Signs with Medical History

• Symptoms of a spinal subdural or epidural hematoma begin with severe local or radicular back pain and percussion tenderness.

• The patient presented with severe abdominal pain radiating to the mid back, along with nausea. A detailed examination revealed epigastric tenderness and soft lower extremity compartments.

  
  

Diagnostic Studies to Rule Out Differential Diagnosis

• A CT of the abdomen and pelvis and a CT angiogram of the chest, abdomen, and pelvis were performed to determine the etiology of the sudden onset of abdominal pain. The results suggested a possible celiac artery dissection with extension into the hepatic artery. Therefore, differential diagnoses for back pain were not considered at that point, as their primary focus was abdominal pain.

Diagnosis and Treatment Plan

• The vascular surgeon recommended starting Aspirin and Lipitor due to low concern for true dissection based on the overall presentation.

• Xarelto was discontinued, and the patient was eventually started on Heparin infusion, Aspirin, and Statin therapy.

Complications

• Despite the above-mentioned treatments, the patient developed an acute onset of bilateral lower extremity weakness with urinary retention and bilateral hip pain.

The Results

Upon reviewing the medical facts, we found out that there was a failure to diagnose the spinal subdural hematoma, despite the clinical presentation of persistent abdominal pain, bilateral back/hip pain, and lower extremity pain/swelling.

• The abdominal pain was misattributed to celiac artery dissection rather than being recognized as referred superficial abdominal wall pain related to thoracic radiculopathy (T5-T9), which supplies nerves to the chest, back, and abdomen. Consequently, early neurology consultation and appropriate imaging studies (such as MRI of the thoracic and lumbar spine) were not pursued.

• In addition, the initiation of Heparin and Aspirin therapy exacerbated the underlying spinal hemorrhage.

• Given the low concern for true dissection, as indicated by the vascular surgeon, it was critical to rule out the underlying cause of the back pain. The presentation of mesenteric dissection was atypical, characterized by diffuse upper abdominal pain not related to food ingestion, accompanied by frequent nausea and emesis.

• Ultimately, the failure to diagnose the spinal subdural hematoma, beginning at the T5-T6 level, delayed necessary surgical intervention. This oversight resulted in progressive bilateral lower extremity weakness, associated numbness, neurogenic bladder, and acute plegia due to spinal hematoma with thecal sac compression.