It's All Spine

It's all Spine

Author: Scott Meester, MD

Peer Review: Matthew Negaard, MD, CAQ-SM

Final Editor: Alex Tomesch, MD

 

A 38-year-old male presents with acute on chronic low back pain. On arrival, he has a fever, 3+/5 strength of the right leg, and 5/5 strength on the left. Sensation to light touch in his bilateral lower extremities is intact with a positive straight leg test bilaterally. 

 

 

Image 1: Case courtesy of Dr. Ahmed Abdrabou, Radiopedia.org, rID: 30706

1.     What is your diagnosis

2.     What is your management in the ED?

3.     What is your disposition?

4.     Can these patients return to sports?

1.     What is your diagnosis?

 

Infectious Spondylodiscitis

 

In patients with atraumatic back pain and new onset neurological dysfunction, one must consider a differential diagnosis of infectious, inflammatory, and metabolic disease leading to damage to the vertebrae or spinal cord [1]. This can include such diagnoses as osteomyelitis, discitis, or ankylosing spondylitis to name a few. In the setting of fever, infectious causes of weakness should rise to the top of the differential. 

• Pearl: Risk factors for infectious spondylodiscitis include HIV, IV drug use, diabetes mellitus, obesity, malnutrition, and foreign bodies [1,2,3].

 

2.     What is your management in the ED?

 

Antibiotics and fluid resuscitation are the initial mainstay of treatment in the Emergency Department with prompt Spine consultation. As such, broad spectrum antibiotics should be initiated after diagnosis. Fungal causes should be considered and if at high risk (such as immunocompromised states) empiric treatment should be started.  [1,2,3]

 

• Pearl: The most commonly isolated infectious organisms include Staphylococcus aureus followed by Escherichia Coli.

3.     What is your disposition?

 

Patients with infectious spondylodiscitis will require a prolonged period of IV antibiotics +/- surgical intervention which may involve abscess drainage, spinal decompression, and fusion [3]. Other cases may only require IV antibiotics, followed by oral antibiotics. Non-operative treatments often result in spontaneous fusion and relief of pain and weakness following healing [2].

4.     Can these patients return to sports?

 

Following resolution of infection, individuals may suffer from spinal deformities and instability [1]. Clearance should be obtained from a spine surgeon and return to sport specific activities should be monitored closely by a physical therapist [1]. 

 

• Pearl: Each athlete attempting to return to participation must be examined on a case to case basis specifically considering the type of sport and the pressure applied to the spinal level by participation [1]. 

 

 

References

 

[1] Metz LN, Wustrack R, Lovell AF, Sawyer AJ. Infectious, inflammatory, and metabolic diseases affecting the athlete's spine. Clin Sports Med. 2012;31(3):535-567. doi:10.1016/j.csm.2012.04.001

 

[2] Smorgick Y, Floman Y, Anekstein Y, Shitrit R, Copeliovitch L, Mirovsky Y. Discitis and isthmic spondylolisthesis: a case report. J Pediatr Orthop B. 2008;17(1):39-41. doi:10.1097/BPB.0b013e3282f1645a

 

[3] Meester S, Hogrefe C. Break up the band: Laparoscopic Adjustable Gastric Banding-associated Discitis and Osteomyelitis. Clin Pract Cases Emerg Med. 2020;4(1):72-74. Published 2020 Jan 21. doi:10.5811/cpcem.2019.11.44879

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