What assessment, differential diagnoses, and management plan should be provided for a 79‑year‑old woman with hypertension, postural hypotension, hypothyroidism, coronary artery disease with left bundle branch block, generalized anxiety disorder, prior schwannoma, gastroesophageal reflux disease, remote bladder cancer, chronic L2 compression fracture and sacral fracture, now presenting after a mechanical fall with acute worsening low back and right thigh pain, new L3‑L5 compression fractures on computed tomography, limited lower extremity motion due to pain, and inadequate analgesia despite intravenous ketorolac and intravenous morphine?

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Last updated: October 8, 2026 • View editorial policy

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Assessment and Plan

Primary Assessment: Acute-on-Chronic Multiple Vertebral Compression Fractures with Severe Pain

This 79-year-old woman with multiple new vertebral compression fractures (L3, L4, L5) superimposed on chronic L2 and sacral fractures requires aggressive multimodal pain management, urgent MRI to exclude cauda equina syndrome, and consideration for vertebral augmentation if conservative management fails within 5 days. 1

Differential Diagnoses

1. Osteoporotic Vertebral Compression Fractures (Most Likely)

  • Primary diagnosis given age, multiple levels, low-energy mechanism (mechanical fall)
  • New L3-L5 fractures on CT with chronic L2/sacral fractures
  • No known malignancy history except remote bladder cancer
  • Requires MRI to assess for bone marrow edema and exclude pathologic features

2. Pathologic Fractures from Metastatic Disease

  • Must be excluded given history of bladder cancer
  • Multiple contiguous levels raise concern
  • MRI lumbar spine without and with IV contrast would be ideal to evaluate for malignancy 1
  • Consider biopsy if imaging ambiguous

3. Cauda Equina Syndrome (Low Probability but High Stakes)

  • Patient denies bowel/bladder dysfunction
  • Limited neuro exam due to pain, but sensation intact, able to retract leg to stimuli
  • MRI lumbar spine without contrast is mandatory to exclude severe central canal stenosis or nerve root compression 1
  • Cannot be definitively excluded on clinical exam alone given pain-limited assessment

4. Spinal Instability

  • Multiple contiguous fractures increase risk
  • Neurosurgery already consulted; recommended LSO brace and conservative trial
  • Vertebral augmentation remains option if immobilizing pain persists >5 days

Detailed Management Plan

1. Acute-on-Chronic Back Pain with Multiple New Compression Fractures

Imaging

  • MRI lumbar spine without contrast (already ordered) - CRITICAL to:
    • Assess for bone marrow edema indicating acute fracture components
    • Exclude central canal stenosis/cauda equina
    • Differentiate osteoporotic from pathologic fractures 1
  • Consider upgrading to MRI with and without contrast given bladder cancer history to definitively exclude metastatic disease 1
  • If imaging findings ambiguous, image-guided biopsy may be needed 1

Pain Management

  • Multimodal analgesia (current plan appropriate):

    • Acetaminophen 1000 mg q6h scheduled (not PRN initially) - safer in elderly with renal/cardiac comorbidities
    • Oxycodone 5 mg PO q4-6h for moderate pain
    • Morphine 2 mg IV q2-4h for severe breakthrough pain
    • AVOID further ketorolac - already received 2 doses IV; FDA limits use to ≤5 days, and in patients ≥65 years, maximum 15 mg IV q6h (max 60 mg/day) due to renal/GI risks 2

  • Dexamethasone consideration:

    • Hold pending MRI results
    • If significant edema present on MRI, consider dexamethasone 4-8 mg daily for anti-inflammatory effect 1
    • Monitor blood glucose given potential for hyperglycemia

Conservative Management (First-Line for 3 Months per Guidelines)

  • LSO (lumbosacral orthosis) brace - order when case management available 1
  • Physical therapy/occupational therapy evaluation - focus on safe mobility, fall prevention, pain-modulated exercises
  • Bowel regimen mandatory - Miralax and senna already ordered (critical with opioid use)

Vertebral Augmentation Decision Point

  • Per neurosurgery and ACR guidelines: If patient cannot ambulate despite adequate pain medications after 5 days, vertebral augmentation (kyphoplasty/vertebroplasty) is appropriate 1
  • For osteoporotic fractures with worsening symptoms or inability to mobilize, percutaneous vertebral augmentation is usually appropriate 1
  • Reassess daily for:
    • Pain control adequacy
    • Ability to participate in PT
    • Development of neurologic symptoms
    • Spinal deformity progression

Malignancy Workup

  • If MRI shows features concerning for pathologic fracture:
    • Multidisciplinary consultation: interventional radiology, surgery, radiation oncology 1
    • Image-guided biopsy if diagnosis unclear
    • Oncology evaluation for systemic therapy

2. Mechanical Fall - Multifactorial Etiology

Fall Risk Assessment

  • Identified risk factors:
    • Age 79
    • Chronic pain limiting mobility
    • Opioid medications (drowsiness noted on exam)
    • Postural hypotension (documented in history)
    • Polypharmacy

Orthostatic Hypotension Management

  • Critical consideration: Patient has documented postural hypotension, which increases fall and cardiovascular risk 3, 4, 5

  • Medication review:

    • Amlodipine 5 mg + lisinopril 10 mg: Both can worsen orthostatic hypotension 3
    • Opioids: Morphine and oxycodone can exacerbate orthostatic hypotension
    • Consider: Holding or reducing antihypertensive doses temporarily during acute pain crisis when opioid requirements high
    • Monitor orthostatic vital signs daily 6

  • Non-pharmacologic measures 6:

    • Increase fluid intake (2-2.5 L/day if no contraindication)
    • Increase salt intake (6-10 g/day unless heart failure concern)
    • Elevate head of bed 10-20 degrees
    • Teach leg crossing, squatting maneuvers before standing
    • Compression stockings (waist-high, 30-40 mmHg)
    • Slow positional changes

Fall Prevention

  • PT/OT evaluation for:
    • Gait assessment when pain permits
    • Assistive device prescription
    • Home safety evaluation
    • Strengthening exercises

3. Essential Hypertension with Postural Hypotension

  • Continue home medications (amlodipine 5 mg, lisinopril 10 mg) with caution
  • Daily orthostatic vital signs mandatory 6, 5
  • If symptomatic orthostatic hypotension worsens:
    • Consider holding morning antihypertensive dose
    • Prioritize fall prevention over strict BP control in acute setting 7, 5, 8
    • Reassess need for dual therapy vs. monotherapy
  • Goal: Balance hypertension control with orthostatic hypotension management 5, 8

4. Sinus Bradycardia with LBBB

  • Asymptomatic - continue monitoring
  • Telemetry if available given opioid use and fall risk
  • No acute intervention needed
  • LBBB is chronic baseline

5. Hypothyroidism

  • Continue levothyroxine 25 mcg daily
  • Stable chronic condition

6. Coronary Artery Disease

  • No acute coronary symptoms
  • Continue monitoring
  • Ensure adequate pain control to minimize cardiac stress

7. DVT Prophylaxis

  • Enoxaparin (already ordered) - appropriate given immobility risk
  • Monitor for bleeding given age and recent ketorolac use
  • Ensure adequate renal function for dosing

8. Baseline Laboratory Monitoring

  • CBC, CMP, magnesium (already ordered) - appropriate
  • Monitor renal function given:
    • Age
    • Ketorolac exposure
    • ACE inhibitor use
    • Potential contrast exposure if MRI with contrast needed

Red Flags Requiring Immediate Escalation

  • New or worsening neurologic deficits (weakness, numbness, saddle anesthesia)
  • Bowel or bladder dysfunction (retention or incontinence)
  • Inability to bear weight despite maximal medical management
  • Hemodynamic instability
  • Acute mental status changes

Disposition Planning

  • Anticipated length of stay: 3-5 days minimum

  • Discharge criteria:

    • Adequate pain control on oral regimen
    • Able to safely mobilize with assistive device
    • PT/OT clearance
    • LSO brace fitted and patient educated
    • Orthostatic hypotension managed
    • Follow-up arranged with neurosurgery, primary care, pain management

  • If unable to mobilize by day 5: Proceed with vertebral augmentation consultation per neurosurgery recommendation 1

Key Pitfalls to Avoid

  1. Underestimating malignancy risk: Remote bladder cancer history + multiple new fractures = need for contrast-enhanced MRI 1
  2. Missing cauda equina: Pain-limited exam is NOT sufficient to exclude; MRI mandatory 1
  3. Ketorolac overuse: Already at maximum safe exposure for age; avoid further doses 2
  4. Ignoring orthostatic hypotension: Major fall risk, especially with opioids; requires active management 3, 6, 5
  5. Premature mobilization: Adequate pain control and bracing must precede aggressive PT
  6. Inadequate bowel regimen: Opioid-induced constipation can worsen pain and immobility

References

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