A 30 yo M presents to the ED complaining of atraumatic lower back pain x 2 days. His pain radiates to his b/l lower extremities. He reports a history of IVDU and labs reveal an elevated ESR and CRP. MRI L spine is obtained and shown below. What's the diagnosis? (scroll down for answer)

Answer: Osteomyelitis/Discitis w/ Epidural Abscess

• Bacteria spreads to the epidural space via contiguous or hematogenous spread
• Risk factors: DM, alcoholism, IVDU, immunosuppression, local/systemic infection (soft tissue infection, osteomyelitis, UTI, endocarditis), spinal intervention (surgery, epidural analgesia)
• Causes injury to spinal cord by direct compression or vascular occlusion due to septic thrombophlebitis
• Signs/symptoms
• Stage 1-back pain at level of affected spine
• Stage 2- radicular pain
• Stage 3- motor weakness, sensory defecit, bladder/bowel dysfunction
• Stage 4- paralysis
• Workup
• CBC, ESR, CRP, blood cultures
• MRI with and without contrast is imaging modality of choice
• Treatment
• Broad spectrum antibiotics (vanco/cefepime), narrow based on cultures; duration up to 6 weeks for osteomyelitis
• Decompressive laminectomy and debridement

References:

Darouiche RO. Spinal Epidural Abscess. N Engl J Med. Nov 2006; 355:2012-2020