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Not Your Usual Aching Back

This case study explores the uncommon presentation of persistent back pain in a 20-year-old male with a history of recent illness. The patient's symptoms did not respond to conventional treatment, leading to further investigation and the diagnosis of vertebral osteomyelitis. The study highlights the importance of considering "red flags" and conducting a thorough evaluation in cases of atypical back pain.

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Not Your Usual Aching Back

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  1. Not Your Usual Aching Back LCDR Sara Saltzstein, MC, USN Family Medicine/Sports Medicine Undersea & Hyperbaric Medicine March 2007

  2. #2-#5 Chief Complaint in Primary Care 90% US Adults 50% US annually $20 billion/yr medical $50 billion/yr total costs 90+% Benign Various musculo-skeletal Evaluate for “Red Flags” Introduction – Low Back Pain…

  3. 20 yo male (USMC LCPL) with Chief Complaint of 3 ½ months of persistent low back pain Unrelenting/progressive, not responding to narcotics Unable to tolerate full duty Wakes up from sleep Case Presentation

  4. Deployed to Iraq Jan 2006 First week of April had fever, back pain, nausea & vomiting. Day #6 acutely worse and medevac’ed to Landstuhl One week in ICU Respiratory fx, Elevated LFT’s, Rhabdomyolysis, Marked Pancytopenia Fever/pulse dissociation Stool Cx – Salmonella Blood Cx – Coag neg Staph (? Contaminant); negative bronch cx Improved with Levaquin, ceftriaxone, vancomycin Returned to U.S. on oral ciprofloxacin and placed on Convalescent Leave History of Present Illness

  5. More HPI… • Illness resolved except persistent back pain and fevers (>102’F qd) • Numerous PCM & ER visits • Ortho Consult • Internal Medicine • R/O Intra-cranial abscess (x2) • Military & Civilian eval’s • Abnormal plain films attributed to Scheuermann’s • All diagnosed with “lumbago” or “backache” • Referred to Sports Med Clinic • Remainder of history and ROS entirely negative

  6. Exam • Afebrile, VSS & WNL • Appeared fatigued • Guarded ambulation • Neuro fully intact • Decreased flexion • TTP upper lumbar vertebrae • Otherwise unremarkable exam

  7. “No price is too great to preserve the health of the fleet.” (Lord St Vincent, 1796)

  8. Plain Films • Non-specific vertebral end plate abnormalities

  9. CT - Extensive lytic process in L1 and L2(Malignancy vs Infection)

  10. MRI - Extensive osteomyelitis of L1 and L2, anterior and bilateral paravertebral abscesses, early signs of autofusion

  11. 90%+ staph, usually no interventions, just atbx This pt unique and needs CT guided aspiration Grew pan-sensitive Salmonella Started cipro x6 weeks Thoraco-Lumbar Orthotic for comfort Vertebral Osteomyelitis

  12. Patient Outcome • One month f/u – pain greatly decreased and increasing ROM • Repeat MRI at 6 weeks showed no change, cipro extended to 16 weeks • Repeat MRI at 16 weeks with some improvement • Improved pain, unable to tolerate axial loading

  13. Typhoid/paratyphoid fever Sepsis, Respiratory fx, bradycardic Hepatitis, pancytopenia Hematogenous>GI Salmonella vertebral osteo 1948-1998 – 46 cases (Santos) 1998 to now – 5 cases Spinal Infections 1.1:10,000 Difficult to diagnose Most will autofuse, non-surgical Prior to atbx 25% fatal Now <5% mortality 7% neuro deficits >30% chronic pain 14% recurrence Discussion

  14. 1876 - Paget noted periostitis of long bones while convalescing from typhoid fever 1889 – Gibney described 4 with “typhoid spine” 1894 – Osler discussed back pain s/p typhoid Labeled “neuroses” & “Typhoid spine” pushed aside 1909 – Halpenny >70 radiographic lesions s/p typhoid – corroborated Gibney’s findings 1916 – Murphy review, 0.87% boney disease s/p typhoid, 1/4 of those being in the spine 1957 – Saphadra & Winter review reported 0.75% osteomyelitis s/p typhoid Historical Review

  15. Conclusion • “Red flags” • Fever • Recent serious illness • Focal tenderness • Uncontrollable & night pain • (Age >50, trauma, neurologic symptoms) • Worrisome findings or unanticipated response indicate need for further work up

  16. Questions?

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