A 78-year-old male was presented to his local orthopedic surgeon for low back pain. The patient had no neurologic deficits, and with the presumptive diagnosis of degenerative spondylosis, he has been treated with non-steroidal anti-inflammatory medications and physiotherapy for 3 months.

The past medical history included hypertension, chronic obstructive pulmonary disease, atrial fibrillation and congestive heart failure. He was receiving b-blockers, loop diuretics, and digoxin for his cardiovascular problems and inhaled corticosteroids and ipratropium for his chronic obstructive pulmonary disease.

Three months later, the patient had worsening of his back pain. Plain radiographs, computed tomography and magnetic resonance imaging of the lumbar spine were obtained, which showed osteoarthritis of the lower lumbar facet joints. Facet joints injection was done using methyl-prednisolone acetate and bupivacaine hydrochloride 0.5%. The patient had temporary relief of his symptoms for 2 days followed by deterioration of his low back pain and acute onset of low-grade fever. Laboratory investigation revealed increased white blood cell count (16.010/ìl), erythrocyte sedimentation rate (83 mm/1st hour), and C-reactive protein (185 mg/l). Spine infection was suspected and ciprofloxacin was administered (500 mg per os, twice a day) for four weeks. However, this treatment led to minimal improvement of the clinical symptoms.

The patient was referred to us for further evaluation and treatment. At the time of his admission, his main signs and symptoms included low back pain and tenderness, and increased body temperature (37.8o). Magnetic resonance imaging of the lumbar spine showed end plate erosions of L3, L4, L5 vertebral bodies (Figure 1) and signal abnormalities at the L2-L3 and L3-L4 intervertebral discs (Figure 2).

What is the appropriate management?

Click here for the diagnosis