Critical Cases - Spine 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 visible uncomfortable lying down on stretcher
  • 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
  • Sciatica


  • CT lumbar and thoracic spine without contrast ordered STAT
  • Basic labs, blood cultures, ESR, CRP, IV pain medicine



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 



  • Neurosurgery consult was called
  • Patient was bladder scanned and retaining >400cc, Foley placed
  • MRI L spine with and without contrast ordered stat
  • Antibiotics held for possible OR
  • MRI eventually showed 4.3cm posterior epidural abscess along with multiple bilateral psoas abscesses and osteomyelitis/ discitis of L4-L5.
  • OR wound cultures were positive for Staph Aureus



  • Spinal epidural abscess is a rare but risk is increased due to IV drug use and spinal procedures 
  • Most often occurs due to hematogenous spread
  • Back pain is the most common presenting complaint and is often the only symptom 
  • MRI is test of choice for diagnosis
  • WBC count/ESR/CRP are not reliable enough to exclude infection


Take Home Message

  • New back pain in an active IV drug use patient is infectious until proven otherwise
  • Don't rely on lower extremity weakness, bowel/bladder incontinence, or saddle anesthesia: these are late findings and denote irreversible damage
  • Don't rely on plain films, labs, or even CT scan to exclude osteomyelitis/discitis/epidural abscess in a high risk patient



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.