A 76-year-old woman is brought to the emergency department due to severe back pain. The patient slipped on a wet tile floor in her bathroom and fell against the toilet; she was unable to stand due to severe pain and was transported to the hospital by ambulance. Medical history is notable for Alzheimer disease and osteoporosis. The patient lives in an assisted living facility.
Vital signs are normal. Examination shows extensive abrasions and ecchymosis across the midback and midline tenderness in the lower thoracic spine. Neurologic examination shows decreased ankle reflexes bilaterally, with normal lower extremity motor strength, sensation, and knee reflexes.
Serum chemistry panel and complete blood count are normal. X-rays of the spine reveal a wedge compression fracture of T12.
Because the patient continues to rate the pain as 9 on a scale of 0-10 despite 2 doses of oral analgesics, she is admitted for parenteral pain control. Which of the following additional measures is indicated at this time?

Question

A 76-year-old woman is brought to the emergency department due to severe back pain.  The patient slipped on a wet tile floor in her bathroom and fell against the toilet; she was unable to stand due to severe pain and was transported to the hospital by ambulance.  Medical history is notable for Alzheimer disease and osteoporosis.  The patient lives in an assisted living facility.
Vital signs are normal.  Examination shows extensive abrasions and ecchymosis across the midback and midline tenderness in the lower thoracic spine.  Neurologic examination shows decreased ankle reflexes bilaterally, with normal lower extremity motor strength, sensation, and knee reflexes.
Serum chemistry panel and complete blood count are normal.  X-rays of the spine reveal a wedge compression fracture of T12.
Because the patient continues to rate the pain as 9 on a scale of 0-10 despite 2 doses of oral analgesics, she is admitted for parenteral pain control.  Which of the following additional measures is indicated at this time?

Quizplus · Accepted Answer

11ec193a_9729_0c89_853d_096b901b0af8_MD0002_00 This patient has acute back pain and vertebral tenderness after a ground-level fall. X-ray confirms a vertebral compression fracture (VCF), likely due to postmenopausal osteoporosis. Initial management of pain following VCF may require simple analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs), opioid analgesics, or, occasionally, inpatient hospitalization for parenteral opioids. If pain persists, calcitonin nasal spray can provide additional pain relief. However, skeletal muscle relaxants are not generally recommended due to adverse effects that are magnified in the elderly population (eg, drowsiness). Patients with VCF should be encouraged to ambulate and resume normal activity as soon as possible. After the pain is controlled and the patient is ambulating adequately, a dedicated course of physical therapy to address core strengthening and gait training for fall prevention can be implemented. Secondary preventive measures include exercise (eg, flexibility and balance exercises, resistance training), management of the underlying osteoporosis (eg, bisphosphonates, calcium, vitamin D), and avoidance of lifestyle risk factors (eg, smoking). (Choice A) Unnecessary bed rest is associated with decreased functional capacity and additional loss of bone density and is not recommended. (Choice C) Pain from acute VCF usually improves within 4-6 weeks. Patients with refractory pain lasting >6 weeks can be considered for vertebral augmentation (eg, vertebroplasty, kyphoplasty), but these procedures are not recommended acutely. (Choice D) X-ray is typically adequate for confirming the diagnosis of VCF, although MRI or CT scan should be considered for patients with significant acute neurologic deficits. This patient's symmetrically diminished ankle reflexes are a common finding in older patients and do not warrant additional imaging. (Choice E) Rigid thoracolumbar braces are not well-studied for VCF. Limited evidence suggests that they are not significantly better than soft braces or no bracing. Educational objective: Following vertebral compression fracture, patients should resume normal activity as soon as possible. Excessive bed rest should be avoided because it is associated with decreased functional capacity and additional loss of bone density. Once the pain improves, physical therapy can be initiated; goals include core strengthening and gait training for fall prevention. __________ References: Exercise for patients with osteoporosis: management of vertebral compression fractures and trunk strengthening for fall prevention. (http://www.ncbi.nlm.nih.gov/pubmed/23174554)

A 76-Year-Old Woman Is Brought to the Emergency Department Due