Subacute Combined Degeneration of the Spine: A Case Study of Delayed Diagnosis in the Emergency Department. 2024 Ryan and Tolby

Abstract

Subacute combined degeneration of the spine (SCDS) is a well-known disease that classically presents with progressive sensory and motor deficits and characteristic magnetic resonance imaging (MRI) findings, leading to its use as a key diagnostic tool. However, clinical and MRI findings in SCDS may be diverse, and thus, a high index of suspicion should be maintained for this disease, which can cause irreversible neurological damage if left untreated.

In this article, we report the case of a 29-year-old female with significant recent life stressors and otherwise unremarkable medical history who presented with progressive weakness of the bilateral lower extremities who previously had unremarkable computed tomography (CT) and MRI completed at an outside hospital for the same symptoms, which had since continued to worsen. Her presentation at our emergency department (ED) prompted urgent evaluation with an MR cord compression study and neurology consultation.

This workup resulted in an unremarkable preliminary MR read, and she was without anemia in laboratory studies. Given this, she was ultimately discharged with high suspicion for conversion disorder. After an addendum report from radiology with concern for subacute combined degeneration of the spine, she was called back to the ED where further workup revealed pernicious anemia leading to SCDS.

This case highlights the importance of maintaining suspicion and avoiding premature closure in patients with reported neurological deficits.

Open access, https://www.cureus.com/articles/267...ayed-diagnosis-in-the-emergency-department#!/

 

This ideology is so dangerous. Life stressors is a completely generic concept and even if present, they can obviously be unrelated. To frame this as "highly suggestive of a conversion disorder" shows just how low the bar is, how it takes nothing at all to jump from absence of evidence to misplaced certainty onto an alternative explanation that requires no explanation and has no scientific evidence.

The only lesson to take from this is that unless the problem is specifically mental health brought by significant trauma, patients should never, ever, under any circumstances, discuss anything having to do with mental health. This is actually the main conclusion here.

This isn't even premature closure, it's closure on the basis of absence of evidence and attachment onto an ideological construct that itself requires zero evidence, in fact is often made despite a complete lack of evidence, hence how common it is to attribute things to repressed trauma or memories.

One day, this rotten ideology will feature heavily in medical training under: What not to do. That is, as long as humanity continues to progress and does not descend into a dystopian nightmare where humans feast on the delicious goo inside other people's skulls.

 

A cynical person (me) might actually start to see the primary goal of this ideology as a very effective way of protecting health care systems from litigation in cases of negligence or failure of duty of care. Because unless there is a blatant mistake such a misreading a test that was indicative of a known condition, it's an unlimited get out of jail card, for individuals, institutions and systems alike. A professional opinion that it was reasonable to go there is always permissible. All it takes is absence of evidence from standard tests.

When they come close to failing, they write papers like this that actually reinforce the process. They explicitly write and cite the importance of the conversion disorder, how any bit of trauma can be blamed onto some imagined "somatization", which will actually cause more such mistakes, not less. It imprints into readers the notion that this is a perfectly valid way of doing things. It may cause the odd misdiagnosis, but nothing to worry about. Those are so rare that only a few case studies are found in the literature. Not that they are all the ones that happen, there is a complete disconnect between those.

When they fail, such as with Maeve Boothby O'Neil and other pwME who have been killed by negligence, they can simply all lie about not having been distracted by the ideology, which protects the system, making it free to keep on making those mistakes. Because it's all so reasonable, and it can only be proven wrong in a tiny % of cases, making it appear very rare. Which they also assert as fact, based on a refusal to record data.

Because as much as they try to make it about how expensive psychosomatic illness is, nothing they have done for decades has changed that. In fact costs have actually increased because they maximize disability, pay for wasted health care services, then pay again for wasted mental health services. So it may be a goal to reduce costs, but it's completely ineffective at it. What it has been effective at is as a very convenient and always-available excuse for any failure, where absence of evidence, encouraged by mandates to do as little testing as possible as soon as ye olde conversion disorder is suspected, can always be cited as a mere mistake made with good professional intentions. And it usually happens under legal gags, so the details are always protected in a no-fault system.

Which is quite similar to drug prohibition, which amplifies literally all the harms associated with drug use, with zero actual benefit outside of people imposing their will onto others. Which isn't an actual benefit, unless you happen to have very different goals in mind than the lie of "harm reduction".

It's not as if, besides harming people, this ideology actually accomplishes anything. As we can see with examples like IAPT and the debacles of chronic illness, far larger today because of Long Covid, it's actually a financial and economic disaster. It serves roughly the same role the mental health exception does with health insurance and disability payments: as an exemption from norms, rules, laws and rights.

 

I really could not agree with you more. It would be simply impossible.

 

Usually termed "subacute combined degeneration of the spinal cord" or simply "subacute combined degeneration" as the brain can also be affected.

From Radiopedia:

The inverted V is nicely shown in the case report, where it's described as "subtle". You do have to look for these things in order to spot them, so this was picked up by neuroradiologists on definitive report. I think the MRI was done to exclude cord compression, which is a much more straightforward rule-out for non sub-specialist or trainees on an overnight read. Neurology were in error assuming the preliminary report was definitive, guided by their cognitive bias toward FND or as they more straight-forwardly refer to it in the paper "conversion disorder".



The loud and clear message for patients presenting for medical help is: deny any life stressors when asked. Reminiscent of "never speak to police without a lawyer present".

 

Yes. It is absolutely crucial to play your cards very close to your chest in this stupid game.