Mr. B, a 51-year-old construction worker, presented to the clinic complaining of low back pain that began after a slip and fall in the shower about one week earlier. He reported no radiation of the pain, which he described as a dull ache. There was no weakness, numbness, or tingling of the extremities. The patient reported no bladder or bowel dysfunction. The discomfort was relieved by rest and increased with activity. Mr. B rated his pain a four or five on a scale of one to 10. He stated that he had taken no analgesics for relief. Mr. B’s medications at the time of presentation included hydrochlorothiazide 25 mg/day, aspirin 81 mg/day (for hypertension), and amlodipine (Norvasc) 10 mg/day. The patient’s physical exam was unremarkable, vital signs were stable, and he was afebrile.
1. Patient history
The patient’s medical history included hypertension and hepatitis C. Mr. B was involved in a motor vehicle accident four years earlier and had sustained a minor injury to his back. There was no report of herniated or bulging disks in his spine. The patient is a smoker and has a history of IV drug use.
Mr. B was treated for a muscle strain. He was advised to take naproxen (Naprosyn) 440 mg b.i.d. as needed and told to avoid strenuous activity for two weeks. He returned to the medical department a few days later complaining that the Naprosyn was not helping. He reported no additional symptoms. The patient’s physical exam was unchanged. Cyclobenzaprine (Flexeril) 10 mg b.i.d. was prescribed, and Mr. B was advised to return if there was no relief of pain. Alternative means of pain relief were discussed. X-ray of the lumbosacral spine revealed mild degenerative changes at L3-L4, characterized by anterior endplate osteophytes. No acute fracture or subluxation was identified.
Mr. B returned a few days later with complaints of pain radiating to his groin and urinary frequency. He reported no dysuria or hematuria. Physical exam revealed mild suprapubic tenderness and no costovertebral angle tenderness. There was mild tenderness on palpation of the lumbar spine. The patient’s strength, sensation, and deep tendon reflexes were normal. Urinalysis was positive for leukocyte esterase and trace blood. The urine culture grew Escherichia coli. Ciprofloxacin 500 mg b.i.d. was prescribed for seven days. Naprosyn was increased to 500 mg b.i.d. as needed for pain, and the patient was advised to come back in one week for reassessment.
One week later, Mr. B returned and stated that his urinary symptoms and the pain to his groin had resolved but described worsening lower back pain. He stated that he could barely stand at times, and complained of increasing difficulty getting out of bed in the morning. Naprosyn “only took the edge off,” but relief did not last long. The pain was constant and seemed to be worse at night. Mr. B was advised to discontinue the Naprosyn and was given a prescription for tramadol (Ultram) 100 mg b.i.d. as needed along with the Flexeril.
Mr. B returned several additional times over the course of the next three weeks. At each visit he complained of severe low back pain. Several analgesics were prescribed without satisfactory relief. A request for orthopedic consultation and MRI of the lumbosacral spine was submitted four weeks after his initial complaint of back pain.
Another week went by and the patient returned, nearly in tears and barely ambulatory. He had not been seen by orthopedics or had an MRI. He complained of excruciating lower back pain (10 on a 10-point scale). The pain had been unrelieved by multiple analgesics and muscle relaxers, including ibuprofen, Naprosyn, Ultram, propoxyphene (Darvocet), oxycodone (Percocet), Flexeril, carisoprodol (Soma), and methocarbamol (Robaxin).
At this point, the pain radiated to his left groin and left lateral leg. There was also stiffness and weakness in the patient’s lower extremities. Mr. B reported no numbness and/or tingling. Urinary frequency and suprapubic tenderness returned. Urine dip was positive for a small amount of blood. Physical exam revealed mild weakness and decreased range of motion in both lower extremities (the left leg was more affected than the right leg). Mr. B’s sensation and deep tendon reflexes remained intact. He had tenderness in the areas of the suprapubic region and over the lumbar vertebrae. The patient was sent to the emergency department for evaluation where he was seen by orthopedics. MRI of the lumbosacral spine revealed evidence of diskitis osteomyelitis at L3-L4.