HPI

• 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

Management

• 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 pain....you 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

Sources:

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.