Case 1:

• Patient had normal basic labs & inflammatory markers and was discharged with return precautions and outpatient follow up. 

Bounceback: 

• Patient was diagnosed with OSTEOMYELITIS.

Case 2

• Construction worker presents with low back pain 
• Rectal tone intact 
• Tachy afebrile (129 bpm temp 98.8F) 
• Repeat visit a couple days later non-focal neuro exam but did have murmur on exam (since childhood) 
• Diaphoretic à febrile via RECTAL TEMPERATURE to 102 
• Diagnosis:
• Bicuspid endocarditis with abscess and severe regurgitation
  
• Also had T12/L1 facet joint infection 

Case 3:

• Patient with history of chronic back pain presenting with lower back pain, radiates to BLE 
• No fevers, hx IVDU when he runs out of pain meds for 3 weeks; similar to prior episodes
  
• No IVDU recently, snorted 4 days prior 
• No weakness, numbness, incontinence, or fevers 
• Given oxy, lido patch and PMD follow up 

Bounceback:

• Fall, normal vitals including temp 
• Rectal temp obtained 101.5 
• Finally admits to IVDU 
• Paresthesias of BLE and weakness (4/5 BLE, +rectal tone) 
• MRI: T8/T9 osteo with epidural abscess went to OR for decompression 

 

WHO DO WE SEARCH FOR THESE BAD SPINAL INFECTIONS AND BACK PAINS? 

• IVDU à trust but verify  
• Diabetics 
• Indwelling catheters (PICC, port) àhematogenous bacterial spread 
• Concomitant soft tissue infections 
• Instrumentation near spine 

Cord Compression:

• Only about ¼ will have weakness or numbness 
• WBC normal in ½, afebrile or fluctuating temp in about ½, ESR normal in 5-10% 
• Usually JUST have back pain!! Then gets paresthesias with compression and can progress rapidly over hours to days 
• Months of pain = NOT protective 
• Early dx is essential bc neuro deficits on presentation are usually irreversible  

 

So how do you work them up? 

• MRI the area above and below pain!!