+ What are the key components of this patient’s history and physical examination?

Relevant History:

• How did this begin? Onset and context of symptoms?
• Location, duration, intensity, quality, radiation, constant/intermittent, aggravating/alleviating factors?
• Is there associated weakness, numbness, tingling, bowel/bladder dysfunction?
• Has this ever happened before?
• Is there a history of trauma/injury/or spine disease?
• Has she sought care for this before, and if so, what has the workup and treatment been so far?
• Any fever, chills, weight loss?
• Functional history and current functional status?
• Family history?
• Past Medical and Surgical History?
• Medications?

Relevant Physical Examination:

• Vital signs
• Inspection
• Palpation
• Gait observation
• Manual muscle testing of bilateral upper and lower extremities
• Sensory and reflex testing of bilateral upper and lower extremities
• Special testing: As directed by history. Possibly lumbar facet loading challenge, FABER, thigh thrust, sacral compression test, Gillet, Yeoman, Gaenslen, Fortin finger, straight leg raise, FAIR, slump sit.

+ Challenge Question

• If the patient says she fell, what would you want to know?

+ Challenge Answer

• Why did she fall? Was she lightheaded? Did she lose consciousness or strike her head? Was it a mechanical fall/did she trip on something? Did she lose her balance in some way? In what position did she strike the ground or other objects? Has she fallen before? Does she live with anyone else? How long was she down? How did she get up? When did the pain begin in relation to the fall timing?

+ What is your differential diagnosis for her back pain?

• Thoracic/lumbar vertebral body compression fracture, paraspinal muscle strain, myofascial pain, lumbar spondylosis, lumbar facet arthropathy, sacroiliac joint dysfunction, discogenic pain, pyelonephritis, nephrolithiasis, vertebral body osteomyelitis.

+ What are your next steps in the workup of her low back pain?

• X-rays of thoracolumbar spine
• Consider CT or MRI of thoracolumbar spine depending on Xray results

+ The results of your workup are below:

• X-rays of thoracic and lumbar spine: anterior wedge deformity of T10 vertebral body with 30% vertebral body height loss.

+ How would you manage this patient?

• I would recommend oral acetaminophen and NSAIDs on a scheduled basis, along with topical lidocaine patch to the low back, and TENS unit as needed. A short course of opioid pain medication would also be appropriate, if needed. I would consider intranasal calcitonin for pain control, as well. I would recommend avoiding spinal bracing, or only using a brace sparingly, as we want to promote core muscle strength, and brace encourages core muscle disuse which can destabilize the spine and predispose to further injury. Avoid bedrest. I would recommend physical therapy for postural mechanics and core muscle strengthening, with avoidance of flexion-biased exercises. I would discuss home safety and even consider a home safety evaluation. If the pain is still intolerable despite these interventions, I would recommend hospitalization for IV analgesia and possible CT scan or MRI of the thoracolumbar spine. I would recommend to the patient’s primary care physician workup for osteoporosis if that has not already been performed recently, with potentially a DEXA scan, bisphosphonate therapy, calcium, vitamin D, and potentially an endocrinologist referral. I would educate the patient that the pain from a vertebral body compression fracture can take weeks to months as it gradually improves. I would ask the patient if there is anything I can help to clarify or any questions I can help answer about anything we’ve discussed today.

+ How would you proceed?

• I would recommend consultation with a spine surgeon for vertebroplasty/kyphoplasty, as this has been shown to improve pain in recalcitrant cases of vertebral body compression fracture. A short course of opioids would be appropriate in the interim. I would advise scheduled acetaminophen, oral NSAIDs, TENS, lidocaine patch, and home exercise program in order to reduce opioid usage as much as tolerable.

+ What is your response?

• Thank you so much for calling to discuss this patient. I appreciate your concern for her. I want to assure you that my goal remains the same as yours, to improve this patient’s pain and function. My goal is to reach this end in the least invasive way possible. Given that there were appropriate nonsurgical options to try first, it was reasonable to see if we could improve her pain to tolerable levels without surgery. Many patients with vertebral body compression fractures will improve without surgical intervention, and of course surgery brings higher risks associated with it. My process is to escalate care only as appropriate, and as soon as I learned that conservative measures were not helping enough, I referred her to your expertise for surgical management, which I agree is very appropriate at this time. I would be more than happy to discuss guidelines and the case in greater detail if you like so that we can reach a mutual understanding and trust. I value our working relationship and hope that we can continue to work supportively and fruitfully together in the future.