Endgames Picture Quiz

A man with back pain

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4132 (Published 20 July 2011) Cite this as: BMJ 2011;343:d4132
  1. B R K Smith, specialist registrar in radiology,
  2. A Shaw, specialist registrar in radiology,
  3. D Howlett, consultant radiologist
  1. 1Eastbourne District General Hospital, East Sussex Hospitals Trust, Eastbourne BN21 2UD, UK
  1. Correspondence to: B R K Smith brksmith{at}doctors.org.uk

A 41 year old man presented to the emergency department with a one week history of severe and worsening lower thoracic back pain. Examination was unremarkable, with no focal neurological signs. His blood tests were normal except for an isolated raised C reactive protein of 21 mg/L (reference range 0-6). Thoracolumbar spine radiographs showed a T11 wedge fracture, which was unchanged from an earlier radiograph taken six weeks previously. This radiograph had been taken after a fall in which he also fractured his left hip, which needed internal fixation. During that admission he was treated for an Escherichia coli urinary tract infection.

At the current presentation he was unable to mobilise and required admission for analgesia. Over the next 48 hours his pain gradually worsened and at day four he developed a fever (39°C). Blood cultures grew E coli. Urgent magnetic resonance imaging of the spine was arranged (fig 1).

Fig 1 Sagittal T2 weighted magnetic resonance imaging scan of the thoracolumbar spine without contrast

Questions

  • 1 What are the radiological findings?

  • 2 What is the most likely diagnosis?

  • 3 What additional investigations may be helpful?

  • 4 How should this condition be managed?

Answers

1 What are the radiological findings?

Short answer

The image shows an anterior wedge fracture of T11 (fig 2). There is abnormal high signal within the T10/11 disc space and destruction of the adjacent vertebral endplates with associated angulation of the spine. Soft tissue is projecting posteriorly and causing narrowing of the spinal canal and compression of the distal cord. Oedema is seen within the T10/11 vertebral bodies.

Fig 2 Sagittal T2 weighted magnetic resonance imaging scan of the thoracolumbar spine without contrast showing abnormal high signal in the T10/11 disc space with destruction of the adjacent endplates (white arrow). The adjacent vertebrae display marrow oedema, and there is cord compression at this …

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