N23) Low back pain after a fall

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with back pain.
  2. Review the DDx considerations in a patient with back pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with back pain.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
A burst fracture or compression fracture are possible in this case considering the new onset radiculopathy in this patient with new onset low back pain after a fall.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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The patient should undergo urgent workup in case they have an unstable fracture.

First Imaging Study

What is the first imaging study you will order?

A lumbar spine radiograph is an appropriate initial imaging modality for this patient with low velocity trauma.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

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Second Imaging Study

What is the next imaging study you will order?

CT is the best imaging modality to evaluate a fracture.
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

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Third Imaging Study

What is the next imaging study you will order?

An MRI can help evaluate the spinal cord and nerve roots.

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

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View the full study if you'd like to like a look yourself

What is your Diagnosis now that you have seen the imaging results?

When two contiguous columns are injured, a fracture is unstable. In this case, all three columns are involved: the anterior (anterior 2/3 of vertebral body), middle (posterior 1/3 of vertebral body), and posterior columns (pedicles and neural arch). Therefore, this fracture is unstable.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

The patient requires urgent management for their spine fracture.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 71-year-old male presenting with an acute unstable L4 burst fracture with retropulsion into the spinal canal and resultant radiculopathy. Neurosurgery should be urgently consulted. In the interim, the patient should be placed on spinal precautions (immobilized, laid flat, and turned only with log-rolls) and administered appropriate analgesia.

Lessons Learned:
- Compression fractures include wedge fractures, split fractures, and burst fractures. Burst fractures involve an endplate and the posterior cortex of the vertebral body.
- Burst fractures with retropulsed segments can result in spinal canal stenosis.
- A compression fracture is unstable when two contiguous columns are involved. The columns are as follows: 
   - Anterior: anterior 2/3 of vertebral body
   - Middle: posterior 1/3 of vertebral body
   - Posterior: pedicles and neural arch

Socioeconomic Factors: Patients with low back pain without red flags presenting for the first time should not undergo routine imaging. A focused history and physical examination should be performed. The patient should be reassured, provided with initial analgesics, and referred to physical therapy if necessary. Red flags include prolonged corticosteroid use, immunosuppression, known or suspected cancer, IV drug use, urinary tract infections, fever, pain not improved with rest, significant trauma, bladder or bowel incontinence, urinary retention, diminished anal sphincter tone, lower extremity motor weakness, point tenderness, limited range of motion of the spine, persistent neurologic findings, and saddle anesthesia.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator

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