How should I evaluate and manage a 17-year-old male with non-traumatic upper-back pain and presyncope when pressure is applied to his spine?

Urgent Evaluation for Serious Spinal Pathology

This 17-year-old male with non-traumatic upper back pain and presyncope on spinal palpation requires immediate MRI of the thoracic spine with and without IV contrast to exclude spinal infection, malignancy, or other serious pathology. The combination of localized spinal tenderness severe enough to cause presyncope is a critical red flag that mandates urgent advanced imaging 1.

Critical Red Flags Present

This patient exhibits several concerning features that distinguish his presentation from benign mechanical back pain:

• Presyncope with direct spinal pressure is an extremely unusual finding that suggests either severe localized pathology (infection, tumor, fracture) or neurologic compromise 1.
• Non-traumatic upper back pain in an adolescent is uncommon and warrants heightened suspicion for serious underlying conditions, as thoracic spine pain is less frequently benign than lumbar pain 2.
• Point tenderness over the spine combined with systemic symptoms (presyncope) raises concern for epidural abscess, osteomyelitis, discitis, or malignancy 2, 1.

Immediate Diagnostic Approach

First-Line Imaging: MRI with Contrast

• Order MRI of the thoracic spine without and with IV contrast immediately as the definitive diagnostic study 2, 1.
• MRI provides superior visualization of the spinal cord, epidural space, vertebral bodies, discs, and paraspinal soft tissues compared to all other modalities 2, 1.
• IV contrast is essential because it delineates enhancement patterns that distinguish infection (rim-enhancing abscess, disc/vertebral enhancement) from tumor (variable enhancement) and characterizes the extent of disease 2, 1.
• Pre-contrast sequences must be obtained to accurately interpret post-contrast enhancement 1.

Do NOT Delay Imaging for Plain Radiographs

• Plain radiographs should NOT be obtained first in this clinical scenario because they are insensitive for detecting epidural pathology, spinal cord compression, early infection, and soft tissue masses 2.
• Negative radiographs do not exclude serious pathology and would only delay definitive diagnosis 2, 1.
• The presence of red flags (presyncope with palpation, adolescent with thoracic pain) bypasses the usual stepwise imaging algorithm 2, 1.

Differential Diagnosis to Exclude

The imaging must specifically evaluate for:

• Spinal infection (epidural abscess, discitis, osteomyelitis) – the most urgent consideration given the potential for rapid neurologic deterioration 2, 1.
• Malignancy (primary spinal tumor such as osteosarcoma/Ewing sarcoma in this age group, or less likely metastatic disease) 2, 1.
• Vertebral compression fracture (pathologic fracture from tumor or occult trauma) 2, 1.
• Spinal cord compression or deformity from any cause 2.

Concurrent Clinical Assessment

While arranging urgent MRI, perform:

• Detailed neurologic examination including motor strength in all extremities, sensory testing in dermatomal distribution, deep tendon reflexes, and assessment for myelopathic signs (Babinski, clonus, gait abnormality) 2, 1.
• Assess for cauda equina/conus medullaris syndrome by asking about urinary retention, fecal incontinence, saddle anesthesia, and bilateral leg weakness 2, 1.
• Check vital signs for fever (infection) or tachycardia (systemic infection/inflammation) 1.
• Screen for constitutional symptoms including unintentional weight loss (malignancy), night pain (tumor/infection), and fever/chills (infection) 2, 1.
• Obtain inflammatory markers (ESR, CRP) and complete blood count if infection is suspected 2.

Management Based on MRI Findings

If Infection Confirmed

• Initiate appropriate antimicrobial therapy immediately 2.
• Obtain neurosurgical consultation for potential surgical drainage of epidural abscess 2.
• Blood cultures and possible image-guided biopsy for organism identification 2.

If Malignancy Identified

• Proceed to image-guided biopsy for tissue diagnosis 1.
• Urgent oncology and neurosurgery referral 1.

If Fracture Without Other Pathology

• Assess for underlying bone pathology (tumor, infection) that caused pathologic fracture 2.
• Consider metabolic workup if osteoporosis suspected (unusual in 17-year-old male) 2.

Critical Pitfalls to Avoid

• Do not attribute symptoms to muscle strain and initiate conservative management without imaging – the presyncope with palpation is not consistent with benign mechanical pain 2, 1.
• Do not order MRI without contrast – contrast is mandatory when infection or tumor is in the differential 2, 1.
• Do not wait for plain radiographs before ordering MRI – this delays diagnosis without adding useful information in this red-flag scenario 2, 1.
• Do not discharge without imaging if MRI cannot be obtained immediately – this patient requires admission for urgent imaging and observation given the concerning presentation 1.

Timeframe for Imaging

• MRI should be obtained within 24 hours given the red-flag presentation, though not necessarily emergently unless progressive neurologic deficits develop 2, 1.
• If progressive motor weakness, sensory loss, or bowel/bladder dysfunction develops, emergent MRI within hours is required 2, 1.