Unrelenting Lower Back Pain in an Uncontrolled Diabetic Patient With an Uncommon Diagnosis

Abstract

Pyogenic spondylodiscitis is an uncommon but important infection that represents approximately 3 - 5% of all cases of osteomyelitis. Staphylococcus aureus is the most frequent causative microorganism that accounts for half of the cases of pyogenic spondylodiscitis. Arachnoiditis is a neuropathic disease with chronic inflammation of the arachnoid layer of the meninges that results in a very debilitating condition. This inflammation can trigger fibrous exudates, leading to the formation of scar tissue that causes the nerve roots to adhere to themselves and or the thecal sac. MRI is the modality of choice for imaging of spondylodiscitis and arachnoiditis due to its high sensitivity and specificity. The patient is a 60 years old female with the complaint of lumbar area back pain for five days that was constant, severe, dull in quality, radiated down legs and was aggravated by movement. Past medical history included uncontrolled diabetes and morbid obesity. The initial blood cultures were positive for methicillin sensitive staphylococcus aureas (MSSA). MRI of lumbar spine showed L4-L5 infectious spondylodiscitis, diffuse lumbosacral infectious arachnoiditis and a right psoas pyomyositis and 7 mm abscess. A PICC line was placed so that the patient could receive an eight week course of ceftriaxone 2,000 mg IV daily. The usual causes of arachnoiditis are infection, spinal surgery, and intraspinal injection of steroid or myelography dye and spinal anesthesia. Spinal arachnoiditis can be diagnosed by myelography, computed tomography, and by magnetic resonance imaging (MRI) in combination with clinical symptoms and history taking. Arachnoiditis is a chronic disorder, with no known cure. It is very important for physicians to consider spondylodiscitis with arachnoiditis in their differential diagnosis when an uncontrolled diabetic patient presents with unrelenting back pain. Much consideration is needed to determine whether a MRI of the spine is needed earlier in the diagnostic process of lower back pain if the etiology seems to be of infectious nature.




J Med Cases. 2013;4(9):602-604
doi: http://dx.doi.org/10.4021/jmc1401w