Endgames Picture Quiz

A sinister cause of back pain in a young man

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3015 (Published 11 May 2012) Cite this as: BMJ 2012;344:e3015
  1. Andrew Brian O’Keeffe, senior house officer in neurosurgery1,
  2. Jane Terris, consultant in emergency medicine 2,
  3. Philip Hormbrey, consultant in emergency medicine2
  1. 1National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
  2. 2Emergency Department, John Radcliffe Hospital, Oxford, UK
  1. Correspondence to: A B O’Keeffe andrewbokeeffe{at}yahoo.com

A 16 year old man presented to the emergency department with a two week history of back pain in the left lower lumbar region. The pain came on suddenly while he was bending over and persisted as a dull ache. The pain was associated with him waking up at night feeling sweaty and feverish. His general practitioner had suspected a urinary tract infection after a urine dipstick tested positive for blood and protein. A course of nitrofurantoin did not improve his symptoms. He presented to the emergency department with difficulty bearing weight on his left leg. He kept his left hip and knee flexed at 45° when lying supine. Systems review was unremarkable. The only positive finding on examination was tenderness over the left paraspinal region at the level of L4-L5, with no associated skin changes.

He had a heart rate of 70 beats/min, respiratory rate of 14 breaths/min, blood pressure of 116/86 mm Hg, and temperature of 36.9ºC. Blood (++) and protein (+) were seen on urinalysis, but no nitrites or leucocytes. Routine blood results were normal except for a C reactive protein >160 mg/L (normal range 0.0-5.0), neutrophils 8.4×109/L (2.0-7.5), and monocytes 1.48×109/L (0.2-1.0). Magnetic resonance imaging (MRI) was performed (fig 1 ).


  • 1 What does magnetic resonance imaging show?

  • 2 What underlying conditions can cause this condition and how should it be investigated?

  • 3 What is the most appropriate treatment in these circumstances?

  • 4 What complications might arise as a result of this condition?


1 What does magnetic resonance imaging show?

Short answer

This STIR (short T1 inversion recovery) MRI scan shows high signal in the L5 vertebral body, with a large paraspinal high signal area that displaces the body of the left psoas muscle laterally (fig 2). There is no abnormality of the intervertebral discs. The most likely diagnosis …

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