Working Diagnosis:
Vertebral osteomyelitis secondary to hematogenous spread vs dry needling.

Treatment:
The MRI had findings suggestive of osteomyelitis and discitis, so the patient was directly admitted to the hospital for a CT biopsy. Basic labs done on admission were notable for elevated WBC, CBC, and ESR. Blood and tissue cultures grew MSSA, but all other serologic studies were negative. CT biopsy histology showed acute inflammatory tissues. He remained in the hospital overnight and was started on oral doxycycline and then transitioned to clindamycin at the advice of infectious disease.


This was continued for eight weeks during which time he returned at regular intervals for repeat labs. His markers of inflammation steadily improved and had normalized at the completion of eight weeks of antibiotics. An MRI was repeated at six weeks with improvement in overall inflammation but with some residual evidence of the prior infectious destruction.

Case Photo #5
Case Photo #6

After eight weeks of treatment, his pain had resolved completely and he had returned to full activity.

Outcome:
Return to full activity with no pain after eight weeks of oral antibiotics.

Author's Comments:
Dry needling is an increasingly popular therapeutic modality in which needles are used to penetrate the skin to stimulate underlying myofascial tissue to activate muscle response and improve pain and ROM. Few serious adverse events have been reported, but infection is among those. It is possible that this patient developed native vertebral osteomyelitis after repeat sessions of dry needling, which explains his initial improvement followed by acute worsening after beginning physical therapy and chiropractic adjustments, followed by sudden worsening and change in character of his back pain. Close follow up and repeat imaging after failure to improve with physical therapy was key for rapid detection and management in this case.

Editor's Comments:
For any patient with back pain, this case is a good reminder to be wary of ‘red flag’ symptoms or sudden change in character of symptoms. This patient appropriately underwent further evaluation upon development of pain that had started to interrupt his sleep, and received timely treatment for this serious condition. More study will need to be done to determine whether, and to what degree, dry needling is a risk factor for deep infection.

References:
Liu L, Huang QM, Liu QG, et al. Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2018;99(1):144-152.e2. doi:10.1016/j.apmr.2017.06.008.

Nigrovic, P. Back pain in children and adolescents: Causes. UpToDate. Published July 19, 2022. Accessed June 5, 2024. https://www.uptodate.com/contents/back-pain-in-children-and-adolescents-causes?search=back%20pain%20in%20children%20and%20adolescents&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1.

Fernandez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review. Pediatrics. 2000 Jun;105(6):1299-304. doi: 10.1542/peds.105.6.1299. PMID: 10835072.

Radi R, Ng W, Simcoe R, Lyon C, DeSanto K. Dry Needling for Low Back Pain. Am Fam Physician. 2023;107(3):299-300.

Return To The Case Studies List.