1. The patient is a 72-year-old woman who presents to the emergency department status post fall with acute low back pain × 2 days. She was diagnosed with an acute compression fracture at T12 due to osteoporosis. Per neurosurgery, she is not a candidate for surgical interventions and, therefore, conservative management is recommended. She was previously independent with functional mobility and ADLs. Unfortunately, her primary limitation of pain warrants supervision—moderate assistance with/without an assistive device for functional mobility. Additionally, due to the pain, she is unable to successfully ascend/descend one step, impairing her ability to enter and exit her home and use bathroom, which is on the second floor. Finally, she has limited social support at home, since her husband continues to work full time. As a result of these, she is not safe to be discharged home. She would benefit from continued inpatient physical therapy for pain management and to maximize functional mobility and safety. Will continue to follow and progress as tolerated.
2. Short-term goals:
Patient will independently perform bed mobility, utilizing logroll technique, within three visits to protect spine and promote independence.
Patient will independently perform all transfers with least restrictive assistive device within three visits to promote independence.
3. Long-term goals:
Patient will be modified independent to ambulate a minimum of 50 feet, using the least restrictive assistive device, within seven visits to promote independence at home.
Patient will be modified independent to ascend/descend a flight of stairs, using one hand rail and a step-to pattern, within seven visits to be able to reach the second floor of home.
Patient will independently verbalize three ways to reduce fall risk within her home within 7 visits to maximize safety.
4. The following is an example of a potential home exercise program for this patient. This exercise program should be prescribed to help prevent disease prevention. Only three to five exercises should be selected to ensure compliance.
Frequency: 2 to 3 days a week
Intensity: moderate, 60 to 80% 1 repetition maximum (RM)
Time: 8 to 12 repetitions
Type: mini-squats, standing hip abduction, bridges
Frequency: 3 to 5 days a week
Intensity: moderate, 40 to < 60% heart rate reserve
Time: 30 to 60 minutes a day
5. The differential diagnoses for a patient with back pain can be broad, and many ruled out through an appropriate history and physical examination.
Referred pain to the back from visceral complaints like pancreatitis (mid-back) or cholecystitis (right scapular) may be excluded in a patient who does not have associated abdominal pain, anorexia, and nausea/vomiting. Rupture of an abdominal aortic aneurysm may also cause referred back pain (mid to lower back). These patients may be identified by risk factors like older age, male sex, history of tobacco use, hypertension, hypercholesterolemia, known cardiovascular disease, etc. Any of these referred pain complaints can also be more definitively ruled out with appropriate imaging studies
Other etiologies for consideration include malignancy or metastatic disease. The most common primary bone malignancy is multiple myeloma. Malignancies most likely to spread to the bone include prostate, thyroid, breast, lung, and renal cancers. These are typically identified on imaging studies but should be considered in patients with history of malignancy or based on other risk factors like advanced age, family history, hypercholesterolemia, and known cardiovascular disease.
Various sources of infection like diskitis, osteomyelitis, or localized abscess may also present with back pain. These patients may have a history of immunosuppression, recent surgery or intervention, other infectious source (endocarditis, bacteremia), IV drug use, and may present with associated symptoms of fever and/or chills. A thorough history can help determine if an infectious etiology should be included on the differential and appropriate imaging can help identify the specific diagnosis
Musculoskeletal considerations for back pain include herniated nucleus pulposus, spinal stenosis, muscular spasm/strain, spondylolisthesis, or bony fracture. A thorough history, physical examination, and appropriate imaging can be utilized to identify these conditions.
6. Cauda equina syndrome is a condition in which the terminal nerve roots of the spinal cord are impinged, which can result in asymmetric multiradicular pain, leg weakness, and/or sensory loss in the lower extremities as well as bowel, bladder, or sexual dysfunction. Although not commonly caused by vertebral compression fractures, it is important to assess for these features in patients presenting with back pain. Failure to recognize and treat cauda equina syndrome in a timely fashion can result in permanent disability. This patient had one episode of urinary incontinence, which prompted the MRI evaluation to assess for integrity of the cord and nerve roots.
7. DEXA technology is used to measure bone mineral density (BMD), which is a reflection of bone strength. It is used to aid in the diagnosis of osteopenia and osteoporosis. The T-score is calculated by subtracting the mean BMD of a young adult reference population from the patient’s BMD, then dividing by the standard deviation (SD) of young adult population. The Z-score is used to compare the patient’s BMD to a population of peers. It is calculated by subtracting the mean BMD of an age, ethnicity, and sex-matched reference population from the patient’s BMD, then dividing by the SD of the reference population.
There are some discrepancies between medical organizations regarding what sites of BMD should be used to make the diagnosis of osteoporosis. The World Health Organization recommends using the T-score measured by DEXA at the femoral neck as the international standard for diagnosing osteoporosis. In contrast, the National Osteoporosis Foundation and the International Society for Clinical Densitometry suggest using the lowest T-score from the lumbar spine (L1–L4), total proximal femur, or femoral neck as determined by DEXA scanning in making the diagnosis of osteoporosis.
8. Risk factors for the development of osteoporosis include advanced age, history of previous fracture, long-term glucocorticoid therapy, low body weight (< 127 lb), parental history of hip fracture, cigarette smoking, excess alcohol use, and race/ethnicity (Caucasian with the highest risk). Of these, the greatest predictors for the development of osteoporosis are advanced age and history of previous fracture.
9. The patient’s blood pressure, heart rate, and respiratory rate are likely elevated due to the patient’s reports of pain and anxiety.
10. Osteoporosis is a disease characterized by low bone mass. There are structural changes to the bone tissue, resulting in bone fragility. This puts an individual at risk of developing fractures, specifically at the hip, spine, and wrist. Osteoporosis, as defined by the World Health Organization, has a T-score less than –2.5. Osteopenia is a term used to describe a decrease in bone mineral density below normal reference values. Osteopenia, as defined by the World Health Organization, is a T-score between –1 and –2.5.