Differential Diagnosis for Acute Onset of Back Pain in a 73-year-old Woman

Single Most Likely Diagnosis

• Osteoporotic Vertebral Compression Fracture: This is the most likely diagnosis given the acute onset of back pain, radiographic evidence of anterior wedging and collapse of the L2 vertebral body, and a recent DEXA scan showing significant osteoporosis (femoral neck T score of -2.3 and lumbar spine T score of -2.2). The patient's age and lack of reported trauma also support this diagnosis.

Other Likely Diagnoses

• Pathological Vertebral Fracture: Although less likely than an osteoporotic fracture, a pathological fracture due to an underlying malignancy (e.g., metastatic cancer) or other bone disease (e.g., multiple myeloma) should be considered, especially if the patient has a history of cancer or other risk factors.
• Disc Herniation or Degenerative Disc Disease: These conditions can cause back pain radiating through the lumbar spine muscles, although they might not fully explain the vertebral body collapse seen on radiographs.

Do Not Miss Diagnoses

• Infection (Osteomyelitis or Discitis): Although less common, spinal infections can present with acute back pain and vertebral body destruction. Missing this diagnosis could lead to severe consequences, including sepsis and neurological deficits.
• Cauda Equina Syndrome: This is a medical emergency that can present with back pain, among other symptoms like urinary retention, fecal incontinence, and bilateral leg weakness. Prompt recognition and treatment are crucial to prevent permanent neurological damage.
• Aortic Dissection or Aneurysm: These conditions can cause severe back pain and are life-threatening if not promptly diagnosed and treated.

Rare Diagnoses

• Vertebral Hemangioma with Fracture: Vertebral hemangiomas are benign tumors that can weaken the bone structure and lead to fractures, although this is a rare cause of vertebral body collapse.
• Langerhans Cell Histiocytosis: This rare condition can cause lytic bone lesions, including in the spine, leading to vertebral body collapse, but it is more commonly seen in younger populations.
• Gastric or Pancreatic Cancer with Metastasis: Although metastatic disease is a consideration in pathological fractures, certain primary cancers like gastric or pancreatic cancer are less common causes of spinal metastases compared to breast, lung, or prostate cancer.