A 67-year-old man comes to the office due to 2 days of back pain. He was moving boxes in his garage when the pain started. The pain is not relieved by lying down and increases in intensity when straining and coughing. He cannot sleep at night due to pain and has taken acetaminophen several times without relief. He has never had such pain before. Physical examination shows 2+ symmetrical knee and ankle jerk reflexes. Straight leg raising test is negative. There is point tenderness to palpation and percussion along the midline at the fourth lumbar vertebra. Which of the following is the most likely underlying etiology of this patient's current condition?

Question

A 67-year-old man comes to the office due to 2 days of back pain.  He was moving boxes in his garage when the pain started.  The pain is not relieved by lying down and increases in intensity when straining and coughing.  He cannot sleep at night due to pain and has taken acetaminophen several times without relief.  He has never had such pain before.  Physical examination shows 2+ symmetrical knee and ankle jerk reflexes.  Straight leg raising test is negative.  There is point tenderness to palpation and percussion along the midline at the fourth lumbar vertebra.  Which of the following is the most likely underlying etiology of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d231_f93d_bc81_d7e4a8e1fe71_MD0003_00 This older patient developed acute back pain associated with vertebral point tenderness after a nontraumatic event, suggesting an acute vertebral compression fracture (VCF). VCF is most commonly due to decreased bone density from osteoporosis. The risk is greatest in postmenopausal women and men age >65 (as in this patient). Uncommon etiologies include osteomalacia, vertebral osteomyelitis, malignancy with bone metastases, metabolic abnormalities (eg, hyperparathyroidism), and trauma. Osteoporotic VCF can be chronic and painless, or may occur acutely due to twisting, lifting, coughing, or minor trauma (eg, fall from standing height), leading to severe midline back pain that is typically localized. The pain often worsens with movement, coughing, or straining and may persist at night. Examination typically demonstrates vertebral point tenderness; however, spinal cord or nerve root compression is rare, and patients usually do not have neurologic deficits. Multiple/recurrent VCF is common and can lead to height loss and kyphosis; complications of kyphosis can include decreased respiratory capacity and abdominal compression (eg, early satiety, weight loss). The diagnosis is confirmed with plain radiography. (Choice A) Apophyseal joint arthritis can occur in spondyloarthropathy (eg, ankylosing spondylitis), which typically presents with chronic, progressive pain that is worse at night and with prolonged rest; symptoms usually begin at age <40. (Choice B) Degenerative disc disease can cause low back pain, but the pain is usually chronic, worsens with activity, and is relieved with rest. Disc degeneration can also lead to acute disc herniation, but this typically presents with acute lumbosacral radiculopathy (ie, pain radiating in a dermatomal distribution). Vertebral point tenderness is more consistent with spinal fracture. (Choice C) Ligamentous back sprain can occur following exertion. However, the pain is usually relieved with rest, and tenderness would be seen in the paraspinal tissues rather than at the midline. (Choice E) Nerve root demyelination (eg, Guillain-Barré syndrome) presents with paresthesia and weakness corresponding to the affected nerve root. It typically is not associated with acute back pain or vertebral tenderness. Educational objective: Acute vertebral compression fracture can be caused by twisting, lifting, or trauma and presents with back pain and vertebral point tenderness. It typically occurs in patients with osteoporosis or other conditions associated with decreased bone mineral density. References: Evaluation and management of vertebral compression fractures. (http://www.ncbi.nlm.nih.gov/pubmed/23251117)

A 67-Year-Old Man Comes to the Office Due to 2