{"id":2635,"date":"2026-05-26T22:10:54","date_gmt":"2026-05-26T22:10:54","guid":{"rendered":"https:\/\/emultrasound.ucsd.edu\/?p=2635"},"modified":"2026-05-27T03:34:38","modified_gmt":"2026-05-27T03:34:38","slug":"case-71-chronic-back-pain","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/2026\/05\/26\/case-71-chronic-back-pain\/","title":{"rendered":"Case 71: Chronic Back Pain"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Letitia Mueller, Bryan Merte, Anthony Medak<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 73-year-old female presented from family health center for \"unbearable\" chronic back pain. She has a complex surgical history, including a T11-sacral posterior spinal fusion and an L3 corpectomy performed at a local outside hospital. She is chronically wheelchair-bound. The patient reported the pain is \"stable\" but reached a breaking point. She described \"notches\" forming on her thoracic spine. She denied acute lower extremity numbness, weakness, saddle anesthesia, or bowel\/bladder incontinence. She denied fevers or recent trauma.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>PMH: <\/strong>COPD on home O<sub>2<\/sub>, Hepatitis C, Major depressive disorder, Polycythemia, Pulmonary embolism, Schizophrenia, Active smoker&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Vitals:<\/strong> BP: 139\/81, Pulse: 61, Temp: 98 \u00b0F, Resp: 16, SpO2: 95% on RA<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Physical Exam:<\/strong><br>General: Alert and oriented x4; non-toxic appearing.<br>MSK: Midline surgical scars over thoracic and lumbar spine. No bony step-offs, no deformity, and notably, no midline tenderness or skin changes.<br>Neuro: 5\/5 strength in all extremities; sensation intact; no focal deficits noted.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Pertinent Labs:<\/strong> WBC 7.4k, Hgb 9.6, ESR &gt;130, CRP 7.15<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A bedside ultrasound was performed.<\/p>\n\n\n\n<figure class=\"wp-block-video\"><video height=\"1172\" style=\"aspect-ratio: 1056 \/ 1172;\" width=\"1056\" controls src=\"https:\/\/emultrasound.ucsd.edu\/wp-content\/uploads\/2026\/05\/Spinal-Abscess-Hardware2.mov\"><\/video><figcaption class=\"wp-element-caption\">Abscess with \"swirl sign\" on compression circled in green.  Reverberation artifact from metal hardware can be seen just deep to the abscess.<\/figcaption><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Learning Questions:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Q1:<\/strong> In a post-surgical patient with a \"benign\" physical exam but elevated inflammatory markers with the above ultrasound findings, what could be considered on the differential diagnosis?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A1:<\/strong> DDx would include: Abscess, seroma, hematoma\u2026. Can you think of more? In this patient, the POCUS \"Swirl Sign\" suggests a purulent\/infectious process. This was later confirmed by blood cultures positive for MRSA.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Q2:<\/strong> What do the cardiac ultrasound findings tell you about the patient\u2019s hemodynamic status?<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A2: <\/strong>The presence of a dilated Right Ventricle and the \"D-sign\" (septal flattening) indicates Right Heart Strain due to severe RV pressure overload. The RV is struggling to pump against significantly elevated pulmonary vascular resistance. This signifies that the patient is at higher risk for cardiovascular collapse.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>ED Course:<br><\/strong>Despite the benign physical exam, the markedly elevated inflammatory markers (ESR &gt;130) and POCUS findings prompted a workup for deep-space infection. MRI of the spine confirmed edema and enhancement surrounding a 6.7 x 5.0 x 3.2 cm fluid collection within the surgical bed, involving a right-sided fusion rod. Patient was transferred to an outside hospital for continuity of care with prior surgical team for fluid drainage and spine hardware removal\/revision.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>During hospital admission:<\/strong><br>Blood cultures confirmed MRSA Bacteremia, likely due to spinal abscess and infected spinal hardware. Patient was started on IV vancomycin and was scheduled for abscess drainage and spinal hardware revision surgery.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Discussion:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">This case illustrates the application of point-of-care ultrasound (POCUS) as a bridge between a benign physical exam and definitive surgical management. A key sonographic finding in this case is the \u201cswirl sign,\u201d characterized by the movement of echogenic debris within a fluid collection when pressure is applied with the transducer. The presence of this \"swirl\" is highly suggestive of a complex collection, such as an abscess, hematoma, or seroma, rather than a simple cyst. In the context of a patient with significantly elevated inflammatory markers (ESR &gt;130), this dynamic debris often points toward the purulent material of an abscess. By identifying this sign at the bedside, clinicians can escalate care, contrary to the approach that a benign physical exam might otherwise suggest. Also, given the artifacts created by metal hardware on MRI and CT, POCUS provides a rapid, non-invasive, and real-time imaging modality that can potentially reduce the time to directed antibiotic therapy or surgical intervention.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Beyond the localized infection, this case highlights the utility of POCUS in pre-operative risk stratification. The patient\u2019s cardiac POCUS revealed a dilated Right Ventricle and a flattened interventricular septum (the \"D-sign\"). This is a hallmark of RV pressure overload, often seen in acute-on-chronic respiratory failure. According to the American Society of Echocardiography, the \"D-sign\" indicates that RV pressures have equaled or exceeded left ventricular pressures.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Despite a benign physical exam, bedside ultrasound identified a deep fluid collection. Additionally, cardiac POCUS provided immediate hemodynamic data, identifying RV pressure overload via the \"D-sign\u201d, which can be used for perioperative risk stratification in a patient with significant pulmonary disease. Ultimately, the bedside findings were confirmed by MRI, demonstrating that POCUS is a reliable tool for that allows for &nbsp;rapid diagnosis and enhanced patient safety in complex surgical cases.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>References:<\/strong><\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.&nbsp;<em>J Am Soc Echocardiogr<\/em>. 2010;23(7):685-788. doi:10.1016\/j.echo.2010.05.010<\/li>\n\n\n\n<li>Spinnato P, Patel DB, Di Carlo M, Bartoloni A, Cevolani L, Matcuk GR, Cromb\u00e9 A. Imaging of Musculoskeletal Soft-Tissue Infections in Clinical Practice: A Comprehensive Updated Review. Microorganisms. 2022 Nov 25;10(12):2329. doi: 10.3390\/microorganisms10122329. PMID: 36557582; PMCID: PMC9784663.<\/li>\n\n\n\n<li>Subramaniam S, Bober J, Chao J, Zehtabchi S. Point-of-care Ultrasound for Diagnosis of Abscess in Skin and Soft Tissue Infections.&nbsp;<em>Acad Emerg Med<\/em>. 2016;23(11):1298-1306. doi:10.1111\/acem.13049<\/li>\n\n\n\n<li>Vieillard-Baron A, Millington SJ, Sanfilippo F, et al. A decade of progress in critical care echocardiography: a narrative review.&nbsp;<em>Intensive Care Med<\/em>. 2019;45(6):770-788. doi:10.1007\/s00134-019-05604-2<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"Letitia Mueller, Bryan Merte, Anthony Medak A 73-year-old female presented from family health center for \"unbearable\" chronic back pain. She has a complex surgical history, including a T11-sacral posterior spinal fusion and an L3 corpectomy performed at a local outside hospital. She is chronically wheelchair-bound. The patient reported the pain is \"stable\" but reached a &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/2026\/05\/26\/case-71-chronic-back-pain\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Case 71: Chronic Back Pain\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[4],"tags":[163,164],"class_list":["post-2635","post","type-post","status-publish","format-standard","hentry","category-clinical-cases","tag-back-pain","tag-epidural-abscess"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Case 71: Chronic Back Pain - UCSD Ultrasound<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/emultrasound.ucsd.edu\/2026\/05\/26\/case-71-chronic-back-pain\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Case 71: Chronic Back Pain - UCSD Ultrasound\" \/>\n<meta property=\"og:description\" content=\"Letitia Mueller, Bryan Merte, Anthony Medak A 73-year-old female presented from family health center for &quot;unbearable&quot; chronic back pain. She has a complex surgical history, including a T11-sacral posterior spinal fusion and an L3 corpectomy performed at a local outside hospital. She is chronically wheelchair-bound. 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