Differential Diagnosis for Acute Back Pain with Radiating Pain to Paralumbar Spine Muscles

Single Most Likely Diagnosis

• Osteoporotic Compression Fracture: Given the patient's age, history of hypertension, significant tenderness to palpation in the mid lower back, serum creatinine of 1.3, X-ray showing lumbar spine anterior wedging of L2 vertebral body and collapse, and a DEXA scan indicating osteoporosis (T-score of -2.2), an osteoporotic compression fracture is the most likely diagnosis. The patient's osteoporosis, as indicated by the low T-score, increases the risk of vertebral compression fractures, even with minimal trauma.

Other Likely Diagnoses

• Degenerative Disc Disease: This condition could cause back pain and radiating pain due to the degeneration of the intervertebral discs, which might be exacerbated by the osteoporotic changes.
• Spondylosis or Spondylolisthesis: These conditions involve defects in the pars interarticularis and could lead to back pain, especially if there is a slip of one vertebral body over another.
• Musculoskeletal Strain: Given the acute onset of pain and tenderness to palpation, a musculoskeletal strain could be considered, although the presence of a vertebral body collapse points more towards a fracture.

Do Not Miss Diagnoses

• Cancer with Metastatic Disease to the Spine: Although less likely, it is crucial not to miss spinal metastasis, which could cause vertebral body collapse and pain. A thorough history and possibly further imaging or biopsy might be necessary to rule out this diagnosis.
• Infection (Osteomyelitis or Discitis): Spinal infections can present with back pain and tenderness, and while less common, they are critical to diagnose early due to the potential for serious complications.
• Aortic Dissection or Aneurysm: Given the patient's history of hypertension, an aortic dissection or aneurysm could present with acute back pain and is a medical emergency.

Rare Diagnoses

• Multiple Myeloma: A plasma cell dyscrasia that can lead to lytic lesions in the bones, including the spine, causing pain and vertebral body collapse.
• Paget's Disease of Bone: A condition characterized by an abnormal breakdown and regrowth of bone tissue, which can lead to deformities and fractures, including in the spine.
• Eosinophilic Granuloma (Langerhans Cell Histiocytosis): A rare disorder that can cause lytic lesions in the bones, including the spine, leading to pain and potential fractures.