Author: Jessica Plotnikov, BS
Co Author #1: Christopher Jou, BS
Co Author #2: Kamalpreet Buttar, MD
Senior Editor: Marc Hilgers, MD, PhD, FAMSSM

Patient Presentation:
62-year-old male presents with a 10-day history of right lumbar pain following feeling muscle spasms after changing his bed sheets. The pain is non-radiating sharp pain that is worse with sitting. He has associated weakness and pain with any movement involving the hips and knees. He has used heat, ice and NSAIDs for the pain, with minimal relief. He denies fever, chills, numbness, tingling, saddle distribution paresthesia, and bowel or bladder incontinence. He denies recent trauma, infections, or drug abuse. He was diagnosed with lumbar muscle strain and he was advised to start a home exercise program, continue using methocarbamol as needed, and get an X-Ray of Lumbar spine.

He returned to the clinic five-days later for follow up. He reports 50% improvement in pain and now is able to lift hips and shift weight in bed. However, he still feels stiff and has not been able to do home exercise. X-ray showed multi-level degenerative changes. Exam showed improved range of motion, gait and strength in his extremities. He was started on Naproxen, counseled to begin home exercise routine, and told to continue methocarbamol as needed, with follow up in 6 weeks.

Patient presented to the clinic 3 weeks later for an acute visit for worsening back pain that began to intensity after a physical therapy session. He now is unable to sit down for a prolonged amount time due to severe pain. He denies neurologic changes or fevers. He was advised to get an MRI of L-spine and started on Percocet and Tizanidine.
Patient presented to the clinic 6 weeks later for an acute visit for worsening back pain after PT. MRI results concerning for discitis-osteomyelitis at L4-L5. The pain has increased to the point where he is unable to sit to do daily activities. Exam showed antalgic gait, ROM limited by pain and diffuse para-spinal tenderness.

Patient sent to the ED and was admitted for IV Antibiotics and IR guided biopsy of L4-L5.

History:
Past medical history
benign prostatic hyperplasia, diabetes mellitus types 2 on insulin, hyperlipidemia, cholelithiasis, nephrolithiasis, macular degeneration, obesity, obstructive sleep apnea on CPAP, anxiety, and depression

Past surgical history
Left knee arthroscopy in 1987, hernia repair 2011, CABG x4 2010, repair of L4-L5 disk in 1998, Back cyst removal April 2018(1 month prior to presentation)

Physical Exam:
General: Obese man. NAD. Vital signs WNL
MSK: Normal posture and no inspected deformities.
ROM: Decreased range of motion in hip flexion, extension , and lateral bending secondary to pain .
Palpation:
L1-Coccyx, Left Paraspinal: No tenderness.
Right Sacral Paraspinal : Slight tenderness.
Strength:
Hip Flexion/Extension: Left: 5/5 Right: 4/5.
Hip Abduction/Adduction: Left: 5/5 Right: 4/5.
Knee Extension/Flexion: Left: 5/5 Right: 4/5.
Sensation: Intact, no deficits.
Straight leg: Left: Positive Right: Positive.
Gait: Uses cane, shuffling gait.

Click here to continue. Challenge yourself by writing down a broad differential diagnosis before moving to the next slide.