Discussion

The MRI image shows a cervical spine with normal age-related changes; however, the thoracic spine has findings suggestive of discitis at T9 to T10 (third intervertebral space up from the bottom of the image), as well as adjacent osteomyelitis. Although these findings do not correspond to the area of pain described by the patient, thoracic discitis can cause significant pain in the upper back and neck area. Therefore, it is often recommended that the thoracic spine be included when obtaining imaging of the lumbar or cervical spine.

When evaluating a patient’s neck pain, it is important to rule out cervical strain, epidural abscess, or a compression fracture. Discitis is not as common as epidural abscess or osteomyelitis. However, if left untreated, it can lead to osteomyelitis with bone destruction, as well as epidural abscess.

The typical presentation of discitis is an insidious onset of spinal pain that tends to be worse with movement and during sleep. Fever and focal spinal tenderness may be present in more severe or advanced cases. Radiculopathy or neurologic findings are absent with isolated discitis.

Risk factors for discitis are similar to epidural abscess and include infection from an indwelling line, urinary tract infection, or endocarditis; injection drug user; being very young or >65 years of age; and having had recent surgery or procedure.

Laboratory workup for discitis is similar to that for osteomyelitis or epidural abscess: a complete blood work to confirm or rule out infection. In the case of discitis, however, leukocytosis is only present in approximately 50% of cases, whereas elevated erythrocyte sedimentation rate occurs in about 80% of cases, making the latter a more sensitive test.

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Imaging tests are diagnostic. Plain radiograph films will typically be normal unless there is already chronic disc-adjacent osteomyelitis (Figure 2). MRI with intravenous contrast is the study of choice and can rule out concomitant epidural abscess. Because the thoracic spine is the most commonly involved site of discitis, and because spinal pain may be referred, the thoracic spine should be imaged in patients who present with primarily cervical or lumbar pain.

The next step in treatment is to consult a spine specialist and consider antibiotics.

Antibiotic treatment of discitis typically includes 6 weeks of intravenous ceftriaxone plus vancomycin. Antibiotic treatment should only be considered if approved by the spine specialist or if the patient appears to be septic or heading in that direction. Surgery is typically only indicated for complications such as abscess or for cases that are refractory to medical therapy (Table).

Table. Discitis

Description• Back/neck pain
• Insidious and often worse at night
• Fever <50%
• Focal tenderness
Risks• Injection drug use
• Pediatric or elderly patient
• Recent procedure
• Endocarditis
• Indwelling line
• Urinary tract infection
Laboratory testing • White blood cells, 50%
• Erythrocyte sedimentation rate, 80%
• C-reactive protein, 80%
• Urine analysis
• Blood cultures
Imaging• Radiograph
• MRI with contrast (always include thoracic region even if pain is cervical or lumbar
Treatment • Intravenous ceftriaxone and vancomycin for 6 weeks
• If complications are present (ie, epidural/paraspinal abscess), surgery is required

Conclusion

The patient was admitted to the hospital, where she received intravenous antibiotics; she did not require surgery.

Brady Pregerson, MD, is an emergency physician at Cedars-Sinai Medical Center in Los Angeles and at Tri-City Medical Center in Oceanside, California.

Reference

Pregerson DB. Emergency Medicine 1-Minute Consult Pocketbook. http://www.erpocketbooks.com/emergency_medicine_reference_books/quick-essentials-emergency-medicine/. 2017;5.