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
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.
- Vertebral osteomyelitis/epidural abscess
- Lumbar spine fracture given hx of MVC
- Lumbar strain
- 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.