Back pain in the older patient.

Clinical history A 72 year old male patient presented with recent onset thoracic back pain. The pain was continuous and intense, exacerbated by movements of the spine, and radiated bilaterally to the costal region. The patient was known to suffer from non-insulin-dependent diabetes mellitus and hypertension. On admission, he appeared unwell and had a fever of 37.5'C. Clinical examination revealed localised tenderness at the T7 level, with bilateral radicular dysaesthesia in the T7-8 area. Conventional radiographs of the thoracic spine were interpreted as showing diffuse idiopathic skeletal hyperostosis (DISH) and degenerative spondylosis (fig 1). The patient was treated with non-steroidal anti-inflammatory drugs, acetaminophen, and muscle relaxants, with improvement of pain, and was discharged from the original admitting hospital three weeks later. Seven days after discharge, he was referred to our hospital because of an acute relapse of thoracic pain associated with febrile episodes. On examination, there was severe tenderness over T6-8, with hypoaesthesia in the T6-7 distribution bilaterally. There were no signs of Figure 1 Conventional thoracic spine radiographs. Left: Frontal view. The T7-8 disc is narrowed, with irregular, ill defined endplates. Paravertebral soft tissue swelling is evident, suggesting paravertebral abscess. Note also spondylosis. Right: Left lateral view. The T7-8 disc is indistinct. Radiological changes of diffuse idiopathic skeletal hyperostosis are evident. spinal cord compression. The temperature was normal on his entry to hospital. The leucocyte count was 10.1 g 1', erythrocyte sedimentation rate (ESR) 125 mm in the first hour, and C reactive protein 140 mg 1' (normal range 0-10 mg 1F'). Radiological findings and diagnosis Plain radiographs were performed and a magnetic resonance imaging (MRI) scan was requested. On frontal view, the plain film showed a narrowed T7-8 disc space, with irregular and ill defined endplates. Paravertebral soft tissue swelling was evident. The lateral view showed an indistinct T7-8 intervertebral disc with radiological changes characteristic of DISH (fig 1). The MRI performed on the day of admission revealed vertebral changes suggestive of T7-8 infective spondylodiscitis: an abnormal signal suggesting oedema and fibrovascular tissue was observed in both vertebral bodies, with a narrowed disc space. Inflammatory soft tissue swelling was demonstrated in the paravertebral and epidural space of the spinal canal, with abscess formation (fig 2). Streptococcus bovis was identified on blood cultures and confirmed by needle biopsy of the intervertebral disc. Treatment with intravenous penicillin and netilmycin was started; the pain disappeared completely within one week, and this …