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Average 4.2 of 42 Ratings
A 69-year-old male presents to the emergency room with low back pain for 1 week duration. His past medical history is significant for diabetes and coronary artery disease that was treated with stenting 7 years prior. Recently he was hospitalized for a urinary tract infection which was treated with oral antibiotics. On physical exam he is afebrile and has no neurologic deficits in his lower extremity. Laboratory studies show a white blood cell count of 10,300/mm3, an erythrocyte sedimentation rate of 35 mm/h (reference range, 0-25 mm/h), and C-reactive protein of 13 mg/L (reference range, 0-5.0 mg/L). A radiograph and MRI are performed and shown in Figure A and B respectively. Repeat blood cultures x2 are performed and both show methicillin-sensitive Staphylococcus aureus. What is the most appropriate next step in treatment.
CT guided biopsy
Referral to an orthopaedic pathologist
Organism specific intravenous antibiotics
Posterior lumbar debridement
Anterior lumbar debridement
Select Answer to see Preferred Response
The clinical presentation is consistent with discitis and vertebral osteomyelitis in a patient without neurologic deficits and an identified organism. Organism specific intravenous antibiotics would be the most appropriate next step in treatment.
Adult discitis and vertebral osteomyelitis is usually seen in adults from 50-60 years of age. Diabetes and IV drug abuse are risk factors. Identifying an organism, either through blood cultures or a biopsy, is critical for successful treatment. The majority of patients can be treated nonoperatively with antibiotics. Surgery is indicated when there are progressive neurologic deficits with evidence of spinal canal compromise, spinal instability, or failure to respond to medical management.
Carragee et al. found that magnetic resonance imaging was able to give the correct diagnosis or suggest a possible diagnosis in 91% of vertebral osteomyelitis cases with less than 2 weeks of symptoms. They concluded that magnetic resonance imaging is valuable in suggesting the diagnosis early in the clinical course and can eliminate significant delays in diagnosis.
Dunbar et al. did a retrospective review of spinal infection database in an effort to identify cases with clinical features suggestive of spinal infection and an MRI that did not show features typical of vertebral osteomyelitis and discitis. They found several such cases and concluded that MRI is the imaging method of choice for vertebral osteomyelitis in the early stages. However, in some cases of vertebral osteomyelitis it can be non-specific and a repeat MRI may be required to show the typical features.
Figure A shows a lateral radiograph that shows loss of definition of the vertebral endplates and disc space narrowing. Figure B shows an MRI consistent with pyogenic vertebral osteomyelitis without evidence of spinal canal compromise.
Answer 1: A CT guided biopsy is not indicated as an organism has been identified by blood cultures.
Answer 2: The clinical presentation and imaging studies are consistent with osteomyelitis and not a tumor.
Answer 4: Because there are no neurologic deficits surgical debridement is not indicated.
Answer 5: Because there are no neurologic deficits surgical debridement is not indicated.
Spine (Phila Pa 1976). 1997 Apr 1;22(7):780-5. PMID: 9106320 (Link to Abstract)
Carragee, SPINE 1997
Dunbar JA, Sandoe JA, Rao AS, Crimmins DW, Baig W, Rankine JJ.
Clin Radiol. 2010 Dec;65(12):974-81. Epub 2010 Jul 7. PMID: 21070900 (Link to Abstract)
Please rate question.
Average 3.0 of 24 Ratings
A 45-year-old female IV drug user presents to the emergency department with a chief complaint of severe focal low back pain that has progressed over the past 10 days. She now reports the pain is severe enough that it is difficult for her to walk. She reports night sweats, fluctuating fever, and a loss of appetite. Physical exam shows exquisite pain with flexion and extension of the lumbar spine. Routine urinalysis by the ER physician shows evidence of a urinary tract infection. Her blood leukocyte count is 12,600 per mm3, and erythrocyte sedimentation rate is 78 mm/h. A lateral radiograph is shown in Figure A. Which of the following would be the most appropriate next step in treatment?
Discharge from the ER with a course of oral antibiotics
Admission to the hospital with empirical IV antibiotics
Admission, blood cultures, and MRI of the lumbar spine with and without gadolinium
Nuclear medicine bone scan
The clinical presentation is highly suspicious of vertebral osteomyelitis of the lumbar spine. An MRI of the lumbar spine with and without gadolinium is the most appropriate next step in management.
Due to the prevalence of back pain in the general population, it is a sensitive but not specific marker of spinal infection. To avoid missing this entity with high morbidity, it is important to look for red flags such as elevated inflammatory parameters (ESR or CRP), tenderness to vertebral palpation, fever, chills, and weight loss.
Carragee reviewed 111 patients with pyogenic vertebral osteomyelitis, unrelated to spinal procedures, and found that risk factors included diabetes and other immune compromised states. The average age was 60, and the most common hematogenous source for infection was the urinary tract.
Frazier et al. analyzed patients with fungal spinal osteomyelitis and found that both diagnosis and treatment were more challenging than bacterial causes.
Hadjipavloa et al. retrospectively reviewed more than 100 cases of pyogenic spinal infections and found, among other things, that back pain was more reliably relieved with surgical rather than non-surgical treament.
Answer 1 & 2: A discharge with a course of oral antibiotics or admission for IV antibiotics may treat the UTI but would not identify the spinal infection.
Answer 4: A bone scan would show increased uptake in the lumbar spine, but is not as specific or helpful as an MRI for localization and planning treatment.
Answer 5: A renal ultrasound would be indicated if the patient had tenderness over the kidneys.
J Bone Joint Surg Am. 1997 Jun;79(6):874-80. PMID: 9199385 (Link to Abstract)
Carragee, JBJS 1997
Frazier DD, Campbell DR, Garvey TA, Wiesel S, Bohlman HH, Eismont FJ.
J Bone Joint Surg Am. 2001 Apr;83-A(4):560-5. PMID: 11315785 (Link to Abstract)
Frazier, JBJS 2001
Hadjipavlou AG, Mader JT, Necessary JT, Muffoletto AJ
Spine. 2000 Jul;25(13):1668-79. PMID: 10870142 (Link to Abstract)
Hadjipavlou, SPINE 2000
Average 2.0 of 44 Ratings
A 33-year-old man with a history of IV drug abuse presents with low back pain of increasing intensity. His neurologic examination is intact. Laboratory studies reveal a WBC count of 11,000/mm3 and erythrocyte sedimentation rate of 82 mm/h. Blood cultures are negative x 3. Plain radiographs are shown in Fig A. An MRI T1-weighted images and a post gadolinium fat-suppressed T1-weighted images are shown in Fig B. Initial management should consist of:
Physical therapy with supportive therapy
Open surgical decompression and biopsy
CT-guided closed biopsy
Repeat MRI in 6 weeks
The clinical presentation is consistent with pyogenic vertebral osteomyelitis. A CT guided biopsy is the most appropriate next step in management to identify an organism and direct antimicrobial therapy.
Adult pyogenic vertebral osteomyelitis is usually seen from ages 50 to 60 years. Risk factors include IV drug abuse and diabetes. Staph aureus is most a common (50-65%) pathogen, but in IV drug users pseudomonas is also seen. In most cases bracing and long term antibiotic (6-12 weeks) therapy is effective treatment. Obtaining a causative organism, either through blood culture or a biopsy, is critical for good outcomes. Indications for surgery include neurologic deficits, progressive deformity, gross spinal instability, and persistent infection.
Tay et al. report that a prompt and accurate diagnosis of spinal infections requires a high index of suspicion in at-risk patients. They emphasize that an evaluation should be focused on identifying the organism and determining the extent of infection.
Carragee et al. reviewed 111 patients with pyogenic vertebral osteomyelitis, unrelated to spinal procedures, and found that risk factors included diabetes and other immune compromised states. The average age was 60. They found the most frequent infecting organism was Staphylococcus aureus (36%). Thirty-seven percent where caused by other organisms, such as Staphylococcus epidermidis, Propionibacterium acnes, and diphtheroid species. The most common hematogenous source for infection was the urinary tract.
Figure A shows a lateral view of the lumbar spine that demonstrates L 3-4 disc space narrowing (arrow) and end-plate irregularity. Figure B shows a sagittal T1-weighted images that demonstrate T1-hypointense signal (panel A - solid arrows) centered around the L3-4 interspace. Post gadolinium sagittal fat-suppressed T1-weighted images shows marrow (panel B - dashed arrows) and disc enhancement with endplate erosions.
Answer A: Physical therapy and supportive therapy (e.g., analgesia) would be encouraged in this patient, however the primary pathology needs to be addressed and managed initially before these measures are implemented.
Answer B: A CT guided biopsy is the most appropriate next step in management to identify an organism and therefore direct antimicrobial therapy
Answer C: There is no indication for open decompression and biopsy as this patient in neurologically intact.
Answer E: Repeat imaging alone would not be sufficient for the management of osteomyelitis.
Tay BK, Deckey J, Hu SS.
J Am Acad Orthop Surg. 2002 May-Jun;10(3):188-97. PMID: 12041940 (Link to Abstract)
Tay, JAAOS 2002
Average 4.0 of 11 Ratings