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Occult infections causing persistent low-back pain
L Schofferman1, J Schofferman, J Zucherman
1SpineCare Medical Group, Daly City, California.
Abstract:
Occult infections caused by indolent organisms may produce persistent back pain that may be difficult to diagnose. The usual findings considered indicative of spinal infection are not reliable in these cases. The authors describe nine patients who presented with occult infections of the lumbar spine. Two of the nine had no antecedent lumbar surgeries nor open wounds. The predominant organisms were diptheroids and coagulase-negative staphylococci. The diagnosis was established by the clinical course, pathologic tissue changes at surgery, cultures, and response to antibiotic therapy. Normal Westergren sedimentation rates were noted in seven of nine patients, and normal white blood cell counts in six of nine patients. With the exception of two positive computed tomography (CT) scans, one positive gallium scan, and one positive magnetic resonance imaging (MRI) scan, all remaining imaging studies were negative for infection. In many cases, the infection neither was limited to nor involved the disc space.
Insights
Occult lumbar spine infections from indolent organisms can cause persistent back pain. Diagnosis is challenging as typical infection markers and imaging are often unreliable, requiring a comprehensive clinical approach.
Area of Science:
- Infectious Diseases
- Orthopedic Surgery
- Diagnostic Imaging
Background:
- Occult spinal infections present diagnostic challenges due to atypical presentations.
- Standard indicators of spinal infection are frequently unreliable in these cases.
- Indolent organisms can lead to persistent back pain that is difficult to diagnose.
Purpose of the Study:
- To describe the clinical characteristics and diagnostic challenges of occult lumbar spine infections.
- To highlight the limitations of conventional diagnostic methods in identifying these infections.
- To emphasize the importance of a multimodal diagnostic strategy.
Main Methods:
- Retrospective case series of nine patients with occult lumbar spine infections.
- Analysis of clinical presentation, surgical findings, microbiological cultures, and treatment response.
- Review of laboratory results (Westergren sedimentation rate, white blood cell count) and imaging studies (CT, MRI, gallium scan).
Main Results:
- Nine patients presented with occult lumbar spine infections, with two having no prior surgery or wounds.
- Predominant organisms identified were diptheroids and coagulase-negative staphylococci.
- Seven of nine patients had normal Westergren sedimentation rates, and six of nine had normal white blood cell counts.
- Most imaging studies were negative, with only two positive CT scans, one positive gallium scan, and one positive MRI scan.
- Infections often extended beyond or did not involve the disc space.
Conclusions:
- Occult lumbar spine infections require a high index of suspicion, especially when typical infection markers are absent.
- Diagnosis relies on integrating clinical course, surgical pathology, cultures, and treatment response.
- Advanced imaging and laboratory tests may be inconclusive, necessitating a thorough clinical evaluation.