HPI

• 55 yo male p/w cc of constant anterior chest pain radiating through to the back for 2 days, constant, dull, worse with movement/bending/twisting, nonpleuritic
• No associated: dyspnea, leg swelling/pain, numbness/weakness in arms/legs, bowel/bladder incontinence, night sweats, or fevers
• +hx of IVDA last use per patient one year prior

Pmhx

• Hypertension

Social

• Nonsmoker, former IVDA

Exam

• T 98.3 HR 61 BP 159/93 SpO2 100% on RA
• General: well appearing in no distress
• Pulm: Clear bilateral
• Cardiac: RRR, no murmurs
• Msk: +TTP over L trapezius and parathoracic area, fully reproduces pain. no midline spinal TTP

Diagnostics

ECG interpretation: NSR, no ST/T wave changes, normal intervals

CXR: negative

DDx: 

• ACS
• Aortic dissection
• pulmonary embolism
• msk back pain
• osteomyelitis/discitis

ED workup and disposition:

• Labs including high-sensitivity troponin, CBC, BMP, and ESR all negative
• Patient was discharged with prescriptions for naproxen and lidocaine patches 

One month later.....

• Pt represents for back pain, now with c/o b/l foot paresthesias and occasional urinary incontinence. 
• Pt notes occasional uncontrollable tremors in b/l LE
• Exam demonstrates 5/5 strength in LE b/l, with +hyperreflexia patellar b/l
• An MRI of the thoracic and lumbar spine is performed which reveals T4/T5  osteomyelitis with adjacent epidural abscess causing cord compression and edema

Clinical course 

• Pt undergoes T4-T5 drainage of epidural abscess and laminectomy with spinal fusion
• After 4 weeks of hospitalization on IV antibiotics, the patient is discharged to rehab with near-full strength in the lower extremities

Take-away points

• Most cases of back pain are benign...until they aren't 
• Patients may be elusive about their IV drug use, fearing bias or prejudice against treatment of their pain
• A frank discussion with the patient of the possible causes of back pain in the setting of active IV drug use is warranted
• Conservative management may involve the assumption that back pain in a former IV drug user is really back pain in an active IV drug user
• An ESR is an insufficient screening test for vertebral osteomyelitis/discitis  in a high risk patient such as an IV drug user
• An MRI is warranted in new, acute back pain in an IV drug user to exclude a potentially catastrophic neurologic outcome from cord compression