Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Di
This was a retrospective analysis using the population-based data of 6 US states from the State Emergency Department Databases and State Inpatient Databases from 2006 through 2012 to identify adults discharged from the ED with a diagnosis of atraumatic headache (which included tension headache, migraine, headache, acute headache, head pain) or back pain (which included lumbar disc herniation, nonspecific disc herniation, back pain including thoracic pain, lumbar back pain or sciatic, thoracic strain, lumbar strain, back strain). There was also a control group of patients with non-neurologic chief complaints. The primary outcome was a composite of return ED visit and hospitalization for primary diagnosis of a serious neurologic condition or inhospital death within 30 days of ED discharge.
They identified 2,101,081 ED patients discharged with a nonspecific diagnosis of headache and 1,381,614 discharged with a nonspecific diagnosis of back pain who were at risk for serious neurologic conditions. Overall, for patients with a nonspecific diagnosis of headache, 0.5% had a serious neurologic condition or inhospital death within 30 days of ED discharge. For patients with a nonspecific diagnosis of back pain, 0.2% had a serious neurologic condition or inhospital death within 30 days of discharge. The frequency of serious event was highest between days 1 and 3 after discharge, with a gradual decline thereafter.
For the control group (discharged with non-neurologic complaint), the incidence of outcomes at 30 days for the headache related missed neurologic emergencies was between 0.12% and 0.18% for the non-neurologic complaints. For back pain related missed neurologic emergencies, the incidence at 30 days was between 0.08% and 0.11% for the non-neurologic complaints.
The most common missed diagnosis for headache was ischemic stroke followed by SAH, and the most common missed diagnosis for back pain was intraspinal abscess (which includes epidural abscess) followed by cauda equina. Advanced age, male sex, non-Hispanic white, several comorbidities (eg, vasculitis, hypertension, neurologic disorders, HIV/AIDS, malignancy), and diagnosis of nonmigraine headache at the index ED discharge were associated with a significantly higher incidence of outcome across the follow-up periods.
This study showed that we do pretty well in ruling out the life threatening causes of headache and back pain, with miss rates lower than 1% and not much higher than if the patient presented with a non-neurologic complaint. The authors do suggest that atypical presentations can be prone to cognitive biases and that reflecting on our own thought processes (metacognition) can help us to avoid those. They also make the valid point of remembering the limitations of our imaging tests since SAH and ischemic stroke were the most common misses for headache. To me the largest limitations of this study were the assumptions that had to be made for data gathering, that (1) the same process that led to the adverse outcome was present at the initial visit and (2) that the same process was misdiagnosed at the initial visit, which may or may not have been true. Also patients could have returned for a totally separate reason within 30 days and had a bad outcome. Overall though, this was a confirmatory study that we have a pretty low miss rate for dangerous presentations of headache and back pain with a reminder to be aware of our own biases and the limits of our diagnostic tests. And of course, always give good return precautions!
Dubosh N, Edlow J, Goto T, Camargo C, Hasegawa K. Missed serious neurologic conditions in emergency department patients discharged with nonspecific diagnoses of headache or back pain. Annals of Emergency Medicine 2019:1-13.