What's the Diagnosis? By Dr. Loran Hatch

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



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