What is the best course of treatment for a patient with a 20-year history of low back pain, elevated C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR), indicating chronic inflammation?

Urgent Evaluation for Spinal Infection Required

This patient with 20-year chronic low back pain and significantly elevated inflammatory markers (CRP 14 mg/dL, ESR 29 mm/h) requires immediate MRI of the spine with and without contrast to exclude vertebral osteomyelitis or epidural abscess before any other treatment is initiated. 1, 2

Critical Red Flag Assessment

The combination of chronic back pain with elevated inflammatory markers constitutes a red flag requiring urgent imaging, regardless of the chronicity of symptoms 1, 2:

• ESR of 29 mm/h and CRP of 14 mg/dL are significantly elevated and warrant immediate investigation for spinal infection, as ESR >50 mm/h and CRP >2.75 mg/dL at 4 weeks predict treatment failure in vertebral osteomyelitis, but any elevation with appropriate clinical context demands evaluation 1
• Vertebral osteomyelitis has a mortality rate of 0-11% in contemporary cohorts, making timely diagnosis critical 1
• Epidural abscess occurs in 2.5-3 per 10,000 patients and is associated with significant neurologic morbidity and mortality when diagnosis is delayed 1

Immediate Actions Before Imaging

Assess for additional red flags that increase suspicion for infection 1, 2, 3:

• Constitutional symptoms: fever, night sweats, unintentional weight loss
• Progressive neurologic deficits: weakness, numbness, bowel/bladder dysfunction (suggesting epidural abscess or cord compression)
• Risk factors for infection: IV drug use, recent spinal procedures, diabetes, immunosuppression, indwelling catheters, recent infection elsewhere

Obtain blood cultures (two sets from separate sites) before starting antibiotics if infection is suspected 2

Imaging Protocol

MRI of the spine with and without IV contrast is the diagnostic test of choice 1, 2, 3:

• Sensitivity 96%, specificity 94%, accuracy 92% for spinal infection 1
• Superior to CT for detecting epidural abscess (CT sensitivity only 6%) 1
• Provides optimal visualization of vertebral marrow, disc spaces, epidural space, and spinal cord 1
• CT with contrast is second-line if MRI is contraindicated (sensitivity 79%, specificity 100% for vertebral osteomyelitis) 1

Common Pitfall to Avoid

Do not assume elevated inflammatory markers are simply related to chronic degenerative disease 4. While one study found mean ESR of 18.8 mm/h and mean hsCRP of 1.1 mg/L in chronic low back pain patients without significant systemic inflammation 4, this patient's CRP of 14 mg/dL (140 mg/L) is more than 100-fold higher than that study's mean and cannot be dismissed as degenerative 4.

Management Based on MRI Results

If MRI Shows Spinal Infection

Start empiric IV antibiotics immediately after blood cultures are obtained 2:

• Vancomycin plus third-generation cephalosporin (e.g., ceftriaxone) for empiric coverage 2
• Obtain tissue diagnosis via CT-guided biopsy when feasible to guide antibiotic selection 1
• Monitor inflammatory markers at 4 weeks: ESR and CRP should decline, though persistent elevation alone does not necessarily indicate treatment failure if clinical improvement occurs 1
• Avoid routine follow-up MRI if favorable clinical and laboratory response observed, as radiographic changes lag behind clinical improvement 1

Surgical consultation is indicated for 1:

• Neurologic compromise
• Significant vertebral destruction with instability
• Large epidural abscess
• Intractable pain despite medical treatment
• Failure of medical treatment

If MRI Shows Malignancy

Urgent oncology referral and consideration of PET/CT for staging 3

If MRI Shows Compression Fracture

Assess fracture age and consider vertebral augmentation (vertebroplasty/kyphoplasty) for acute fractures with severe pain 3

If MRI is Negative for Serious Pathology

Only after excluding infection, malignancy, and fracture should you proceed with standard chronic low back pain management 1, 5, 6:

Nonpharmacologic treatment is first-line 1, 5, 6:

• Exercise therapy (moderate-quality evidence) 5
• Multidisciplinary rehabilitation (moderate-quality evidence) 5
• Acupuncture (moderate-quality evidence) 5
• Spinal manipulation (low-quality evidence) 5
• Cognitive behavioral therapy (low-quality evidence) 5

Pharmacologic treatment if nonpharmacologic therapy inadequate 1, 5, 7, 6:

• First-line: NSAIDs (e.g., naproxen 500 mg twice daily) at lowest effective dose for shortest duration 5, 7, 6
• Second-line: Tramadol or duloxetine if NSAIDs insufficient 5, 6
• Avoid long-term opioids except as last resort with careful monitoring 5, 6

Alternative Diagnoses to Consider

If imaging excludes infection but inflammatory markers remain elevated, consider 2:

Polymyalgia rheumatica (PMR) if patient >50 years with:

• Bilateral shoulder and hip girdle pain
• Morning stiffness >45 minutes
• Trial of prednisone 12.5-25 mg daily if suspected 2, 8

Inflammatory arthritis: Check rheumatoid factor, anti-CCP antibodies, ANA 2

Repeat ESR and CRP in 2-4 weeks to determine if elevation is persistent or transitory 2

Follow-Up Strategy

Do not proceed with routine chronic low back pain treatment until serious pathology is excluded 1, 5, 2. The elevated inflammatory markers override the 20-year chronicity of symptoms and mandate urgent evaluation 1, 2, 3.