A 65-year-old white woman comes to the physician for acute mid-thoracic back pain. Seven days ago, she slipped and fell in her driveway and has had the back pain ever since. The pain is described as deep-seated, boring in quality, and non-radiating, and has not improved with over-the-counter pain medications. Her past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with fluticasone, salmeterol, and ipratropium inhalers, and hypertension treated with lisinopril and hydrochlorothiazide. She has had occasional brief courses of oral glucocorticoids for COPD exacerbations. The patient has a 30-pack-year smoking history and quit approximately 5 years ago. She experienced menopause when she was 48 years old. Her mammogram and Pap smear were negative 6 months ago. Her mother and 2 sisters have osteoporosis. Examination shows tenderness over the mid-thoracic vertebrae. The rest of the examination is unremarkable. The complete blood count, basic metabolic panel, calcium, and phosphorus are within normal limits. Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and 11th vertebrae.
In addition to pain control, what is the best next step in management of this patient?

Question

A 65-year-old white woman comes to the physician for acute mid-thoracic back pain.  Seven days ago, she slipped and fell in her driveway and has had the back pain ever since.  The pain is described as deep-seated, boring in quality, and non-radiating, and has not improved with over-the-counter pain medications.  Her past medical history is significant for chronic obstructive pulmonary disease (COPD) treated with fluticasone, salmeterol, and ipratropium inhalers, and hypertension treated with lisinopril and hydrochlorothiazide.  She has had occasional brief courses of oral glucocorticoids for COPD exacerbations.  The patient has a 30-pack-year smoking history and quit approximately 5 years ago.  She experienced menopause when she was 48 years old.  Her mammogram and Pap smear were negative 6 months ago.  Her mother and 2 sisters have osteoporosis.  Examination shows tenderness over the mid-thoracic vertebrae.  The rest of the examination is unremarkable.  The complete blood count, basic metabolic panel, calcium, and phosphorus are within normal limits.  Plain radiographs of the thoracic spine reveal a compression fracture in the 10th and 11th vertebrae. 
In addition to pain control, what is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0b5_2531_8f63_11844672e7e9_MD0005_00 This patient has back pain due to multiple vertebral compression fractures following a fall from a standing height. She has multiple risk factors for bone loss including white ethnicity, family history of osteoporosis, smoking, prior glucocorticoid use, and postmenopausal status. Fractures following a ground-level fall suggest abnormal bone fragility, likely due to postmenopausal osteoporosis. Confirmation with measurement of central (ie, spine and hip) bone density is recommended, preferably with dual-energy x-ray absorptiometry (DEXA). Bone mineral density (BMD) is an excellent predictor of fracture risk in postmenopausal women; the fracture risk increases as the BMD decreases. Under World Health Organization (WHO) criteria, postmenopausal osteoporosis can be diagnosed with DEXA based on T-score (number of standard deviations above [+] or below [-] the mean for a healthy 30-year-old of the same gender and ethnicity). By convention, a T-score -1 and above is considered normal; a T-score between -1 and -2.5 is considered osteopenia; and a T-score of -2.5 or lower is considered osteoporosis. The WHO classification may also be used for men age >50; however, it should not be used in patients age <50 because the relation between T-score and fracture risk is not as well documented in this population. (Choice B) This patient has normal calcium and phosphorus levels and has no clinical features to suggest hyperparathyroidism. Measurement of parathyroid hormone level is not required in the routine assessment of postmenopausal osteoporosis. (Choice C) Devices to measure peripheral bone density, such as heel ultrasounds, can predict fracture risk; however, monitoring the patient's response to treatment using a peripheral device has not been studied and validated. Furthermore, the diagnostic criteria established by the WHO are only applicable for central DEXA measurements. (Choice D) Quantitative CT measures volumetric bone density of the hip and spine. It is used primarily in research settings, but is not recommended in clinical practice due to lack of validation to predict fracture risk, greater expense, and higher radiation exposure compared to DEXA. (Choice E) Although a bone scan may differentiate old from new vertebral fractures (increased uptake is seen in new compression fractures), it does not eliminate the need for DEXA and is unlikely to change management in this patient. Bone scan is a very sensitive but nonspecific test used for investigating a wide variety of skeletal disorders, including osteomyelitis, bone metastasis, Paget's disease, and arthritis. Educational objective: Patients with a fracture following minor trauma such as a ground-level fall should be tested for osteoporosis using dual-energy x-ray absorptiometry. References: Bone mineral density testing after fragility fracture: informative test results likely. (http://www.ncbi.nlm.nih.gov/pubmed/24336562)

A 65-Year-Old White Woman Comes to the Physician for Acute