A 75-year-old woman comes to the emergency department due to a day of severe low back pain. The pain started after she lifted a turkey from the freezer and worsens with standing, walking, and lying on her back. She had no recent falls, lower extremity weakness, or sensory loss in the legs. The patient has a history of temporal arteritis, which was diagnosed several months ago and is being treated with prednisone. She does not use tobacco or alcohol. Temperature is 36.7 C (98.1 F), blood pressure is 140/70 mm Hg, pulse is 80/min, and respirations are 16/min. Physical examination shows midline tenderness to palpation or percussion of the lumbar spine. Ankle jerk reflexes are absent bilaterally. Knee reflexes are 2+ in both legs. Flexor plantar responses are present bilaterally. Muscle strength is 5/5 in both legs. Bilateral straight-leg raising test to 90 degrees does not increase the pain. Which of the following is the most likely diagnosis in this patient?

Question

A 75-year-old woman comes to the emergency department due to a day of severe low back pain.  The pain started after she lifted a turkey from the freezer and worsens with standing, walking, and lying on her back.  She had no recent falls, lower extremity weakness, or sensory loss in the legs.  The patient has a history of temporal arteritis, which was diagnosed several months ago and is being treated with prednisone.  She does not use tobacco or alcohol.  Temperature is 36.7 C (98.1 F), blood pressure is 140/70 mm Hg, pulse is 80/min, and respirations are 16/min.  Physical examination shows midline tenderness to palpation or percussion of the lumbar spine.  Ankle jerk reflexes are absent bilaterally.  Knee reflexes are 2+ in both legs.  Flexor plantar responses are present bilaterally.  Muscle strength is 5/5 in both legs.  Bilateral straight-leg raising test to 90 degrees does not increase the pain.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d215_9772_bc81_6b8797260d7e_MD0003_00 This patient has an acute vertebral compression fracture (VCF), which typically presents with back pain and decreased spinal mobility after bending, coughing/sneezing, or lifting (even small weights). The pain typically increases with standing, walking, or lying on the back. Gradual-onset VCF can be asymptomatic and noted incidentally on imaging performed for other reasons; multiple compressions are often seen. VCF is common, with a prevalence of ~25% in women age ≥50. It is usually due to osteoporosis, which is likely in this woman age 75 with a history of systemic glucocorticoid use. Additional risk factors include other metabolic bone disorders (eg, hyperparathyroidism, osteomalacia), infection (eg, osteomyelitis), and malignant bone metastasis. VCF can also occur in patients with normal bone density following severe trauma (eg, fall from a height). Examination may show localized midline/spinal tenderness. Neurologic deficits are usually absent; this patient's absent ankle reflexes are likely due to normal aging and are not clinically significant. Large or repeated VCF may be visible as kyphosis or loss of height. The diagnosis is confirmed on x-ray, which most commonly shows an anterior wedge deformity. anterior wedge deformity (Choice A) Facet joint dislocation usually occurs following a severe deceleration injury (eg, motor vehicle collision). It is most common in the cervical region (C7-T1). Bilateral dislocation causes spinal cord injury, and unilateral dislocation results in radicular symptoms. (Choice B) A herniated disk usually presents with radicular pain radiating along the thigh to below the knee (ie, sciatica). Patients can have a positive straight-leg raising test due to nerve root compression. straight-leg raising test (Choice C) Lumbosacral strain can occur after lifting a heavy object, and the pain is often worse with ambulation. However, the pain and tenderness are typically in the paraspinal area without significant midline tenderness. This patient's age and history of glucocorticoid use greatly increase the likelihood of VCF. (Choice D) Lumbar spinal stenosis is characterized by narrowing of the intraspinal (central) canal, lateral recess, or neural foramen. It causes chronic, progressive back pain with neurologic symptoms (eg, sensory loss, leg weakness) that are worse with spinal extension and improved with leaning forward or lying down. This patient's acute symptoms are more consistent with VCF. worse with spinal extension Educational objective: Vertebral compression fracture, a common complication of osteoporosis, often presents with acute back pain following minimal trauma (eg, bending, coughing/sneezing, lifting). Examination may show localized midline/spinal tenderness, but neurologic examination is typically normal. References: Evaluation and management of vertebral compression fractures. (http://www.ncbi.nlm.nih.gov/pubmed/23251117)

A 75-Year-Old Woman Comes to the Emergency Department Due to a Day