CC: Back pain

HPI: 61 yo M with PMHx DM, HTN, HCV c/o lower back pain x 2 days. The pain is located bilat but L>R and radiates down his LLE. Described as 9/10 and sharp/shooting.  Seen two days ago and had CT T and L spine that showed herniated discs and neural foraminal stenosis.  Taking acetaminophen without relief. Denies F/C/N/V/D/CP/SOB or upper back pain. . Pain is better when laying flat. Denies saddle paresthesias,  leg numbness/weakness, difficulty urinating, urinary or fecal incontinence. Denies recent infection, no hx of cancer, and no IVDU. In 2006 he suffered a severe back injury after falling in a hole- was diagnosed with herniated discs at that time. Works as a trash collector.

PE:

VS: BP  149/107 | Pulse 134 | Temp 99.5 °F (37.5 °C) (Oral) | Resp 18 | SpO2 97%

Cardiovascular: Reg rhythm, tachycardic, no murmur.

Pulmonary/Chest: Clear

Abdominal: Soft and nontender

Musculoskeletal:+b/l T anbd L paraspinal TTP 

Rectal: normal rectal tone, no prostate tenderness

Neurological: He exhibits normal muscle tone. 5/5 strength  BLE but severe pain with movement of LLE and +straight leg raise test.

Ddx:

• Sciatica secondary to known herniated discs 
• Spinal stenosis
• Osteomyelitis/discitis/epidural abscess
• Epidural hematoma
• Pathologic fracture
• Consider: AAA/dissection (HTN, smoker, male), nephrolithiasis/pyelonephritis

Management:

• CBC/chem/ua all unremarkable
• CT a/p to assess for ureterolithiasis: negative
• Rpt vitals: T 102.1F  HR 120s
• MRI of his T and L spine: Epidural abscess T11/T12
• Neurosurg consult: to OR for decompressive hemilaminectomy
• Cultures grew MSSA

Pearls:

• Back pain usually benign, until it is not
• Beware bouncebacks: intensify workup on second visit, consider consultation and/or admission
• Spinal epidural abscesses most common complaints in decreasing order: back pain > fever > focal neuro deficit; triad only in 8-37% of patients
• MRI is the study of choice for high clinical suspicion
• TIME IS OF THE ESSENCE → neuro outcome is correlated with degree of deficit prior to NSG intervention

Reference: Tanski ME and Ma OJ. Central Nervous System and Spinal Infections. In: Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8e. New York, NY: McGraw-Hill.