Faculty Bibliography

Case/Program Description: The patient is an 88-year-old woman with history of hysterectomy who was referred for evaluation of acute onset low back and buttock pain of 2 weeks duration without any reported provocation or injury. The pain was 4/10, intermittent, aching, exacerbated by walking, alleviated by resting, sitting, Tylenol and Advil. There were no associated fevers, chills, radicular symptoms, bowel or bladder dysfunction, reported changes in weight, prior or recent injections or instrumentation of the spine. Exam was notable for an antalgic gait, pain with end flexion and bilateral oblique extension, tenderness over paraspinal muscles and facet joints as well as the left sacroiliac joint and posterior superior iliac spine. Motor, sensory, and deep tendon reflexes were intact. Setting: Outpatient Spine Center. Results: Lumbar radiographs showed multilevel degenerative disc disease, spondylosis, and multilevel facet arthrosis. Patient was started on naproxen and referred to outpatient physical therapy. She presented for early follow up 11 days later, with increasing 7/10 pain radiating to left anterior thigh. Exam notable for new tenderness over anterior midthigh, positive left Ober test, reproduction of left anterior thigh pain with Ely test, mild weakness of left hip flexors and diminished left lower reflexes. Lumbar MRI showed left L3-4 facet joint abnormality, adjacent marrow edema, and soft tissue abscess of the multifidus and psoas muscles. She was emergently referred for inpatient admission, and required a prolonged hospitalization. Discussion: Psoas abscess is a rare infectious disease with nonspecific clinical presentation and often insidious onset that frequently results in diagnostic difficulty and delays. Delays are often associated with high morbidity and mortality in these patients. Conclusions: It is crucial to maintain a high index of suspicion for infectious etiologies and utilize a combination of laboratory and imaging studies when working up back pain