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You are seeing a 3 year old child with 3 weeks of gradually progressing low back pain, now impacting her ability or willingness to walk. There has been no trauma and no fever noted at home, although temperature is 37.8 in the ED. On exam she has loss of lumbar lordosis and tenderness to palpation of the lumbar spine. She has full passive range of motion without pain of the hips. She was seen by her PCP 3 days ago and CBC was normal, blood cultures negative to date. Today, CBC is still normal and ESR is 47. Plain radiograph shows narrowing of the L3/4 disc space. MRI is not available in your ED.
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April 21, 2023 at 11:17 am
C) Broad spectrum antibiotics
The patient’s presentation is classic for discitis, inflammation (and likely low-grade infection) of an intervertebral disc. Discitis is most common in preschool age children and in the lumbar spine. Patients commonly present with back pain, refusal to bend over, loss of lumbar lordosis, refusal to walk or limping. Less commonly they may have fever, neurologic findings, ileus. WBC count is often normal, blood cultures negative, but ESR is typically elevated. Plain films show narrowing of the intervertebral disc space, but diagnosis is best made by MRI. Many patients would improve spontaneously without antibiotics, but IV antibiotics to cover Staph aureus and Kingella kingae are commonly given, along with analgesics and rest. Prognosis is good.