A 62-year-old man comes to the office after a week of persistent back pain. The patient has had back pain before, but this episode is more disturbing. The pain is limited to his lower back, becomes worse with movement, and persists at night. He has no leg pain or abdominal symptoms. Three weeks ago, the patient was evaluated for fever, urinary frequency, and dysuria. He was found to have an enlarged, nontender prostate with a prostate-specific antigen level of 2.2 ng/mL (normal

Question

A 62-year-old man comes to the office after a week of persistent back pain.  The patient has had back pain before, but this episode is more disturbing.  The pain is limited to his lower back, becomes worse with movement, and persists at night.  He has no leg pain or abdominal symptoms.  Three weeks ago, the patient was evaluated for fever, urinary frequency, and dysuria.  He was found to have an enlarged, nontender prostate with a prostate-specific antigen level of 2.2 ng/mL (normal <4 ng/mL), and was prescribed a 7-day course of ciprofloxacin.  Except for mild malaise, the symptoms have subsided.  The patient's medications include vitamin D and daily fiber supplements.
Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, and pulse is 88/min.  The patient has limited mobility of his back in all directions due to pain.  There is no tenderness on palpation of any of the spinal processes.  There is no costovertebral angle tenderness.  Gait, perineal sensation, and deep tendon and plantar reflexes are normal.  The remainder of the examination is normal.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9936_8fa1_853d_8db9d7842176_MD0002_00 Low back pain is usually due to self-limited musculoskeletal causes; most cases do not require diagnostic testing and can be managed with conservative measures (eg, mild analgesics, moderation of activity) (Choice B). However, patients with features that increase the probability of an underlying malignancy or infection warrant further diagnostic testing. This patient has red flags (recent urinary tract infection, age >50, nocturnal pain) that suggest an infectious etiology, and further evaluation is indicated. Vertebral bone is highly vascular and is vulnerable to hematogenous seeding by bloodborne organisms from distant sites (eg, genitourinary tract). Vertebral osteomyelitis typically presents with progressively worsening spinal pain over several weeks or months. Examination can show spinal percussion tenderness and decreased range of motion but may be unremarkable. The erythrocyte sedimentation rate is elevated in >80% of patients, but other systemic features of infection (eg, fever, leukocytosis) are inconsistent. Blood cultures should be obtained and can identify the organism (most commonly Staphylococcus aureus) in a majority of cases. MRI is more sensitive than CT scan and is preferred in the initial evaluation, although subsequent CT-guided needle biopsy is often performed for confirmation and to obtain material for culture. (Choice A) Abdominal ultrasound is helpful for diagnosing a ruptured abdominal aortic aneurysm. However, the lack of acute severe pain, hypotension, and a pulsatile mass makes this diagnosis less likely. (Choice D) Radionuclide scanning is usually reserved for patients with suspected osteomyelitis and negative/nonspecific CT scan or MRI. (Choice E) Prostate massage prior to urine culture has been advocated for evaluation of prostatitis but is painful and may induce bacteremia without substantially increasing diagnostic yield. This patient has had improvement in his urinary symptoms, does not have evidence of prostatitis (eg, nontender prostate, normal prostate-specific antigen), and has completed a course of antibiotics; a urine culture would likely be negative and not helpful. Educational objective: Vertebral osteomyelitis presents with progressively worsening back pain over weeks or months and is often due to hematogenous seeding by organisms from distant sites (eg, genitourinary tract). The erythrocyte sedimentation rate is usually elevated, and blood cultures and MRI of the spine are indicated in the initial evaluation. __________ References: Hematogenous vertebral osteomyelitis. (http://www.ncbi.nlm.nih.gov/pubmed/19753920)

A 62-Year-Old Man Comes to the Office After a Week