Review Question - QID 3359

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Adult Pyogenic Vertebral Osteomyelitis Epidemiology Risk factors include QID: 3359 (OBQ10.271)

QID 3359 (Type "3359" in App Search)

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?

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Discharge from the ER with a course of oral antibiotics

53/3334

Admission to the hospital with empirical IV antibiotics

211/3334

Admission, blood cultures, and MRI of the lumbar spine with and without gadolinium

89%

2979/3334

Nuclear medicine bone scan

10/3334

Renal ultrasound

63/3334

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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.

Incorrect Answers:
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.