Critical Cases - Back pain emergency!


  • 53 year old male with a history of IVDU and 1.5 months of “stabbing” lower back pain
  • Reports he was riding his bike 2 days ago and was hit by a car that acutely worsened the pain
  • Reports difficulty urinating, lower extremity weakness, straining with BM, fevers, chills, weight loss, and thigh pain

Physical Exam

T 97.1 BP 152/72 HR 80 RR 22 Pox 100% on RA

  • Pt is visibly uncomfortable 
  • Moving all extremities with pain on passive movement of both legs
  • L posterior thigh tenderness with obvious mass on deep palpation
  • Tenderness to percussion on L spine 
  • CN II-XII intact. Strength is 5/5 UE and LE. Sensation intact-no saddle anesthesia. Rectal tone intact. Patient is able to ambulate.


Differential Diagnosis

  • Vertebral osteomyelitis/epidural abscess
  • Lumbar spine fracture given hx of MVC 
  • Lumbar strain/msk pain


  • Initial imaging: CT lumbar and thoracic spine 
  • Blood cultures, ESR, CRP, CBC, Chem 7


CT imaging


  • Findings consistent with discitis and osteomyelitis at L4-L5, bilateral psoas abscess, and a suggestion of spinal canal phlegmon or abscess with severe stenosis

Followup MRI:

  • MRI: 4.3cm posterior epidural abscess along with multiple bilateral psoas abscesses and osteomyelitis/ discitis of L4-L5.
  • Pt taken to OR for abscess evacuation 
  • OR cultures grew S Aureus


Take Home Points

  • Back pain in a patient with hx of IVDU = infection
  • Back pain in a patient with hx of IVDU = infection
  • Back get the idea
  • MRI with contrast best study to evaluate for spinal osteomyelitis
  • Any neuro deficits on presentation are likely permanent --> rapid neurosurgical intervention is key to prevent progression



Tanski M, Ma O. Central Nervous System and Spinal Infections. In: Tintinalli JE, Ma O, Yearly DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e.