Emergent spinal MRI in IVDU patients presenting with back pain: do we need an MRI in every case?

Postoperative spinal cord infarction on a gravid woman with suspected IV drug use: a case report

BACKGROUND

Back pain is common in the gravid population and spinal cord infarction (SCI) or chronic osteomyelitis are exceptionally rare underlying causes of back pain in this population. No case report to date has described this unexpected adverse event in a gravid woman with suspected history of IV drug use (IVDU). This diagnosis could potentially become more common with increasing rates of IVDU, and increased education could result in sooner recognition.

CASE

A 38 year old G9P0171 at 24 weeks gestation with a complex past medical history, and a suspected history of IVDU, presented repeatedly with back pain. Following cesarean delivery at 36w2d, she developed signs and symptoms of an anterior spinal artery syndrome (ASAS) and had evidence of chronic osteomyelitis at T9-T10 on imaging. This required emergent decompressive laminectomy and ultimately resulted in paraplegia.

CONCLUSION

This case highlights the difficulties in recognizing all SCI risk factors pre-operatively and the importance of investigating back pain in pregnant patients with a suspected history of IVDU. We believe this patient's chronic infection put her at an increased risk for SCI that was possibly compounded by the anatomical changes from its chronicity, possibly occurring in combination with several other precipitating causes of hypoperfusion. We hope this case report highlights the modern necessity to include a history, or suspected history, of IVDU as a red flag to initiate imaging in pregnant patients with acute, persistent, or unresolved back pain.

ACR Appropriateness Criteria® Suspected Spine Infection

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Cracking the Opium Den: Cardiothoracic Manifestations of Drug Abuse

Recreational drug use is increasing worldwide, with emergency room visits and total deaths from drug overdose rising in recent years. Complications from prescription and recreational drug use may result from the biochemical effects of the drugs themselves, impurities mixed with substances, or from causes related to the method of drug administration. The presentation of drug overdose may be complex due to multisubstance abuse, including cigarette smoking and alcoholism, and can impact any organ system. Patients may present without history, and radiologists may be the first clinicians to suggest the diagnosis. We aim to explore the cardiothoracic manifestations of drug abuse and their multimodality imaging manifestations.

The Emergent Evaluation and Treatment of Neck and Back Pain

Neck and back pain are among the most common symptom-related complaints for visits to the emergency department (ED). They contribute to high levels of lost work days, disability, and health care use. The goal of ED assessment of patients with neck and back pain is to evaluate for potentially dangerous causes that could result in significant morbidity and mortality. This article discusses the efficient and effective evaluation, management, and treatment of patients with neck and back pain in the ED. Emphasis is placed on vertebral osteomyelitis, epidural abscess, acute transverse myelitis, epidural compression syndrome, spinal malignancy, and spinal stenosis.

Infectious Spondylitis Mimics: Mechanisms of Disease and Imaging Findings

Infectious processes of the spine are on the rise; in this scenario recognition of entities imitating infection is very important. The discovertebral unit is regarded as one of the most important and active sites in the spine. Importantly, the vertebral bony rim and the anterior corners of the vertebral bodies have significant vascularization, they are the last regions to ossify in the developmental process and suffer mechanical forces. Early septic or aseptic discitis-osteomyelitis, properly called spondylitis, involves these anterior regions. Early degeneration is characterized by disc desiccation; however, there is preferential involvement for the corners of the vertebral bodies as well. Many entities to include degenerative changes, inflammatory spondyloarthropathies, neuropathic spine, or pseudo arthrosis, among others, affect the discovertebral unit and can imitate infection. With some exceptions, important imaging findings for the identification of an infectious mimic include the absence of soft tissue enhancement or fluid collections in the paraspinal or epidural regions, and the involvement of multiple levels or the posterior elements. We review developmental, anatomical, and pathologic concepts correlating with imaging clues. Overall, our goal is to increase awareness and to improve recognition of mimicking entities.