Working Diagnosis:
Cervical spine discitis of C4-C7 and cervical osteomyelitis

Treatment:
The patient was admitted and underwent cervical biopsy by neurosurgery where they subsequently performed a C5-C7 corpectomy and C3-T1 posterior surgical fusion. Cervical cultures later grew Streptococcus dysgalactiae. ID was consulted however a source for this particular Streptococcus species was never identified. The patient finished an eight week course of IV ceftriaxone at home.

Outcome:
He developed dysphonia and oropharyngeal dysphagia after surgery. The patient met with a speech language pathologist which resolved the dysphagia, but he continued to have mild dysphonia secondary to suspected traction on the recurrent laryngeal nerve. The patient's neck pain has mostly resolved and he can now lift fifty pounds. He returned to many of the activities he once enjoyed.

Author's Comments:
The annual incidence for vertebral osteomyelitis is 2.9 to 5.4 per 100,000 with diskitis being even less common. Spinal pain remains in the top ten most common reasons for an office visit by clinicians in the primary care setting. This patient had a couple red flags including pain awakening him from sleep and reduction in light touch sensation on exam. He denied other red flags: weakness, ambulation change, bowel or bladder incontinence, fever, IV drug use, immunosuppression, chronic steroids, unexplained weight loss, and prior cancer history. This case illustrates the importance of identifying red flags as a critical skill set to separate the ordinary from emergent and the common presentation for the uncommon problem.

Editor's Comments:
This case serves as an excellent reminder of the need for a thorough history and physical exam. A previously healthy middle-aged hiker with no known risk factors would not be expected to present with cervical diskitis or cervical osteomyelitis. By obtaining a thorough history and physical examination red flag symptoms of decreased sensation and pain awakening him from sleep could be elicited. This prompted a more aggressive workup with emergent MRI and admission to the hospital for treatment.

References:
1. Finley CR, Chan DS, Garrison S, et al. What are the most common conditions in primary care? Systematic review. Can Fam Physician. 2018;64(11):832-840.
2. Muscara JD, Blazar E. Diskitis. [Updated 2021 Aug 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK541047/

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