Critical Cases - Back pain bounceback!


  • 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


  • Hypertension


  • Nonsmoker, former IVDA


  • 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





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

CXR: negative



  • 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