What is the best course of management for a 24-year-old patient with spastic pain in the spine area that worsens at night and has been ongoing for 1 year?

Management of 24-Year-Old with Chronic Spastic Spine Pain Worsening at Night

This patient requires urgent imaging with MRI complete spine without and with IV contrast to rule out neoplasm, infection, or inflammatory disease, as persistent nighttime pain for 1 year in a young adult is a critical red flag that demands immediate investigation.

Critical Red Flags Present

This patient has multiple concerning features that mandate urgent evaluation:

• Night pain is the most common symptom of spinal neoplasm, present in 25-30% of children and young adults with spinal tumors 1
• Pain duration of 1 year constitutes chronic pain requiring investigation for serious underlying pathology 1
• Young age (24 years) makes mechanical causes less likely and raises concern for inflammatory conditions like ankylosing spondylitis, which typically presents in late adolescence/early adulthood with nighttime awakening and morning stiffness 1

Immediate Diagnostic Workup

Laboratory Testing (Obtain Before Imaging)

• Complete blood count, ESR, and CRP to evaluate for infection or inflammatory disease 1
• These labs help differentiate between infectious, inflammatory, and neoplastic etiologies 1

Imaging Protocol

• MRI complete spine without and with IV contrast is the gold standard for suspected infection, inflammation, or neoplasm 1, 2
• The contrast component is essential to demonstrate enhancement patterns that differentiate tumor, infection, and inflammation 2
• Do not order MRI with contrast only - this is explicitly rated as "usually not appropriate" as it lacks the non-contrast baseline needed for proper assessment 2
• Plain radiographs are insufficient as initial imaging given the duration and red flags, though they may be obtained concurrently 1

Differential Diagnosis to Exclude

Neoplastic Causes (Highest Priority)

• Benign tumors: osteoid osteoma, osteoblastoma, aneurysmal bone cyst, giant cell tumor 1
• Malignant tumors: leukemia, lymphoma, rarely metastasis 1
• Intramedullary tumors: astrocytoma (45-60%) and ependymoma (30-35%) are most common intraspinal tumors 1

Infectious Causes

• Vertebral osteomyelitis and discitis present with persistent nighttime pain, low-grade fever, decreased range of motion, and localized tenderness 1
• Elevated ESR and CRP support this diagnosis 1

Inflammatory Causes

• Ankylosing spondylitis should be strongly considered given the patient's age and nighttime pain pattern 1
• Classic features include morning stiffness, improvement with exercise, alternating buttock pain, and awakening during the second part of the night 1
• Juvenile idiopathic arthritis can affect the spine, though more commonly cervical 1

Management Algorithm

Step 1: Urgent Evaluation (Within 48-72 Hours)

1. Obtain CBC, ESR, CRP immediately 1
2. Order MRI complete spine without and with IV contrast 1, 2
3. Perform thorough neurological examination to assess for motor deficits, sensory changes, or signs of cauda equina syndrome 1

Step 2: Symptomatic Management While Awaiting Results

• NSAIDs for pain control if not contraindicated 3
• Avoid opioids as first-line therapy 3
• Do NOT pursue spinal injections - the BMJ 2025 guideline provides strong recommendations against epidural injections, joint injections, or radiofrequency ablation for chronic spine pain 1

Step 3: Definitive Management Based on Imaging

• If neoplasm identified: urgent oncology or neurosurgery referral 1
• If infection identified: infectious disease consultation and appropriate antimicrobial therapy 1
• If inflammatory arthropathy: rheumatology referral for disease-modifying therapy 1

Common Pitfalls to Avoid

• Do not dismiss nighttime pain as mechanical - this is a cardinal red flag for serious pathology 1
• Do not delay imaging - catastrophic consequences can result from delayed diagnosis of infection or neoplasm 1
• Do not order MRI with contrast only - always include non-contrast sequences 2
• Do not pursue conservative therapy first - the presence of red flags (nighttime pain, 1-year duration, young age) mandates immediate investigation 1
• Avoid interventional procedures - strong evidence recommends against spinal injections and ablation for chronic spine pain 1

Spasticity Management (If Confirmed as Symptom)

If true spasticity is present (velocity-dependent increased muscle tone from upper motor neuron lesion):

• First-line: physiotherapy and stretching exercises 4, 5, 6
• Oral baclofen is first choice if medications needed, though efficacy is limited with considerable side effects 4, 5
• Identify and eliminate triggers: bladder distension, constipation, infections, pressure ulcers 5, 6
• Botulinum toxin injections for localized spasticity combined with physiotherapy 4, 5

However, true spasticity requires an upper motor neuron lesion 4, 6, making urgent imaging even more critical to identify the underlying spinal cord pathology.