Emmanuel Villalpando, MD
Resident Physician
Casa Colina Hospital & Centers for Healthcare
Winnetka, California, United States
Phillip Ahn, BS
Medical Student
Western University of Health Sciences - College of Osteopathic Medicine of the Pacific
Irvine, California, United States
Brian Vu, MD
Resident Physician
Casa Colina Hospital and Centers for Healthcare
Pomona, California, United States
Ethan Izu, BS
Medical Student
California University of Science and Medicine
Irvine, California, United States
Hunter Goldsmith, MD
Resident Physician PGY-2
Casa Colina
Pomona, California, United States
Richard Martirosian, MD
Resident
Casa Colina
Burbank, California, United States
Maryrose Zavaro, MMSc
Medical Student OMS IV
LECOM
El Cajon, California, United States
The patient presented to the emergency department for low back pain radiating down the left leg and difficulty ambulating after a ground level fall. MRI lumbar spine showed L4-5 disc herniation, moderate central canal stenosis, and left L5 root impingement. Neurosurgery initiated gabapentin and decadron, but no surgical intervention was indicated.
After transfer to acute rehabilitation, the patient developed recurrent fevers, worsening back pain, and sepsis. Despite empiric antibiotics, the patient’s status worsened with bilateral leg weakness. Repeat MRI lumbar spine revealed L4-5 discitis, worsening disc herniation, and central canal stenosis. Given worsening functional status and concern for spinal abscess, Neurosurgery performed a bilateral L4-5 laminectomy with partial facetectomy, right L4-5 discectomy. Upon finding an epidural abscess, an evacuation was performed. Cultures were positive for Escherichia coli. Follow-up CT abdomen and pelvis performed for additional source identification was negative. Patient’s strength and pain improved with increased therapy participation. Discitis is often due to hematogenous spread from UTIs, contiguous spread from adjacent osteomyelitis, or direct inoculation. Early detection is challenging given initially unremarkable laboratory and imaging. The initial infectious workup in this case was unremarkable. However, the patient’s worsening functional status despite antibiotics prompted MRI re-imaging and eventually Neurosurgical intervention. Intraoperative cultures confirmed diagnosis of discitis and were positive for E. coli, suggesting possible intra-abdominal source, but ultimately the seeding source was not identified. Our case highlights the diagnostic and interventional difficulties that may be inherent in treating this elusive pathology.
Discussions:
Conclusions: Infectious pathologies should be considered in a differential diagnosis in patients with traumatic disc herniation experiencing worsening functional symptoms. Early recognition and interventions are critical to improve functional, mortality, and morbidity outcomes.
