A 50 Year-Old Woman Is Brought to the Emergency Department

A 50 year-old woman is brought to the emergency department due to a sudden back pain after lefting a heavy box. She has no weakness in the lower extremities. during evaluation, she reports an irregular menses and episodes of hot flashes. she has a history of hypothyroidsim and takes levothyroxin. She recently has been diagnosed with rheumatoid arthritis so methotrexate accompined with predinslone are prescribed. The patient does not use tobacco, alcohol, or illicit drugs, and she consumes a balanced diet. Physical examination shows point tenderness over the midthoracic spine. The straight-leg raising test is negative, and neurologic examination of the lower extremities shows no abnormalities. Spine imaging is shown below: Which of the following contributed most to this patient's current condition?

A) Inadequate levothyroxine replacement
B) Medication adverse effect
C) Nutritional vitamin deficiency
D) Ovarian hormone deficiency
E) Vertebral joint inflammation