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Consideration of psychological factors for pain led to missed diagnosis of spinal abscess (01HDC03147)

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(01HDC03147, 20 June 2003)

Neurosurgeon ~ Public hospital ~ Spinal abscess ~ Osteomyelitis ~ Standard of care ~ Explanation of condition ~ Misdiagnosis ~ Pain management ~ Co-ordination of providers ~ Rights 4(1), 6(1)(a)

A 49-year-old woman had suffered a retropharyngeal abscess, which had been drained. Over a period of about six weeks after discharge, she presented to the Emergency Department frequently with severe pain. She was eventually diagnosed with an epidural abscess with osteomyelitis in her cervical spine. Her complaint was that the neurosurgeon inappropriately decided she did not need an MRI scan, inappropriately ceased her antibiotic treatment, did not provide her with adequate pain relief over the period of six weeks, and treated her as though the pain she was experiencing was the result of a psychiatric, not medical, condition.

The Commissioner held that the neurosurgeon breached Right 4(1) because he failed to properly investigate the patient's physical condition, and should at least have requested a CT scan. The X-ray indicated that, despite being on antibiotics, the patient had an infection that had spread to her vertebrae. There should have been further attempts to investigate the cause of the infection, even though there was no indication of neurological deterioration.

The neurosurgeon also breached Right 4(1) in ceasing the patient's antibiotics prematurely when her infection markers were high, suggesting an uncontrolled infection in her spine. However, mitigating factors included the difficulty in diagnosing and treating spinal abscesses, the complex circumstances surrounding the patient's treatment, and the fact that several providers from different disciplines were involved over a short period.

Although psychological and social factors can be very important in diagnosis and treatment, it appeared that they had been given too much weight at an early stage instead of excluding a physical explanation for the patient's pain and other symptoms. Psychiatric or psychological factors should have been considered only once all other conditions had been excluded.

The neurosurgeon did not breach Right 6(1) because, even though the patient was not properly informed about the importance of psychological matters in her diagnosis and treatment, the lack of information provided to her was a result of the neurosurgeon's uncertainty about the persisting causes of her condition.

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