A 72-year-old man presents with 4 weeks of central low back pain. His pain was initially mild and relieved by recumbency. Over the past two weeks, the pain has increased in severity and occurs at night without relief by lying down. The pain does not radiate and he has neither sensory loss nor weakness in his legs.
The patient has benign prostatic hyperplasia with significant outlet obstruction. He is scheduled for a transurethral prostatectomy soon. He was treated for a urinary tract infection both 3 years ago and two months ago. He has a history of stable coronary artery disease, hypertension, and degenerative joint disease. He has no history of cancer.
His temperature is 37.8 C (100.1 F), blood pressure is 140/72 mm Hg, and pulse is 84/min. Cardiac, pulmonary, and abdominal exams are unremarkable. There is decreased range of motion in all aspects of his back. Point tenderness is present over the third and fourth lumbar processes. There are no sensory or motor deficits in his lower extremities. Deep tendon reflexes are symmetric. Perineal sensation and rectal tone are normal. An enlarged, non-tender rubbery prostate is palpated on digital rectal examination.
The patient's labs reveal:

Which of the following is the most appropriate next step in management?

Question

A 72-year-old man presents with 4 weeks of central low back pain.  His pain was initially mild and relieved by recumbency.  Over the past two weeks, the pain has increased in severity and occurs at night without relief by lying down.  The pain does not radiate and he has neither sensory loss nor weakness in his legs.
The patient has benign prostatic hyperplasia with significant outlet obstruction.  He is scheduled for a transurethral prostatectomy soon.  He was treated for a urinary tract infection both 3 years ago and two months ago.  He has a history of stable coronary artery disease, hypertension, and degenerative joint disease.  He has no history of cancer.
His temperature is 37.8 C (100.1 F), blood pressure is 140/72 mm Hg, and pulse is 84/min.  Cardiac, pulmonary, and abdominal exams are unremarkable.  There is decreased range of motion in all aspects of his back.  Point tenderness is present over the third and fourth lumbar processes.  There are no sensory or motor deficits in his lower extremities.  Deep tendon reflexes are symmetric.  Perineal sensation and rectal tone are normal.  An enlarged, non-tender rubbery prostate is palpated on digital rectal examination.
The patient's labs reveal:

Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_9911_06dd_853d_2d4fb7b05bfd_MD0002_00 This patient's clinical presentation is most concerning for vertebral osteomyelitis, most commonly occurring in males over age 50. The majority of low back pain is due to musculoskeletal causes, but the above red flags suggest a systemic disorder. Bacteria from an infected genitourinary source may spread to bone or travel into the lumbar vertebrae and adjacent structures via Batson's venous plexus (present in males). Patients typically present with pain initially relieved by bed rest that eventually worsens at night, point tenderness to palpation on examination, and elevated ESR (sometimes > 100 mm/h). A vertebral body or interspace infection is likely in this patient with a history of infected and obstructive uropathy, constitutional symptoms, subjective fever, and an erythrocyte sedimentation rate of 90. A spinal MRI is the most sensitive test for detecting vertebral osteomyelitis. Treatment is with intravenous antibiotics and surgery for those who do not improve with antibiotics. (Choices A and C) Pain control with either NSAIDs or acetaminophen with oxycodone may be effective as initial treatment of simple back pain in a patient without red flags for systemic illnesses or anatomic pathology. If a patient fails treatment after 2 weeks, further investigation can be done at that time with MRI or CT. (Choice D) Prostate biopsy is indicated if digital rectal examination shows nodules, induration, or asymmetry. However, it would not be diagnostic in this patient with known prostate enlargement, infection, and scheduled prostatectomy. (Choice E) Serum protein electrophoresis (SPEP) helps in the diagnosis multiple myeloma. However, this patient's clinical presentation is more concerning for an infectious etiology and warrants a MRI. Educational objective: Low back pain that persists with red flags for systemic illness warrants immediate evaluation rather than conservative therapy. A recent urinary tract infection associated with back pain is concerning for vertebral osteomyelitis, and MRI is the most sensitive test for diagnosis. __________ References: Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. (http://www.ncbi.nlm.nih.gov/pubmed/18550153) Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society (http://www.ncbi.nlm.nih.gov/pubmed/17909209)

A 72-Year-Old Man Presents with 4 Weeks of Central Low