What is the best course of action for a patient with a history of Addison's disease, taking daily prednisone, who presents to the emergency department with right lower back pain after a fall onto their back?

Emergency Department Imaging for Fall with Right Lower Back Pain in Patient on Chronic Prednisone

Plain radiography should be obtained immediately in this patient to evaluate for vertebral compression fracture, given the combination of trauma, chronic glucocorticoid use, and localized back pain. 1

Critical Risk Factor: Glucocorticoid-Induced Osteoporosis

This patient has a high-priority indication for imaging that overrides the usual recommendation against routine imaging in acute low back pain:

• Chronic prednisone use for Addison's disease places this patient at significantly elevated risk for vertebral compression fractures 1
• The American College of Physicians explicitly identifies "history of osteoporosis or steroid use" as a specific indication for plain radiography in the initial evaluation of low back pain after trauma 1
• The 2017 American College of Rheumatology guidelines emphasize that patients on chronic glucocorticoids (≥2.5 mg/day prednisone for ≥3 months) require fracture risk assessment and are at substantially increased fracture risk 1

Imaging Algorithm for This Patient

Initial imaging:

• Plain radiography (2 views of lumbar spine) is the appropriate first-line test to screen for vertebral compression fracture 1, 2
• This provides adequate visualization of bony structures while minimizing radiation exposure and cost 1

Proceed to advanced imaging (MRI or CT) if:

• Plain films demonstrate fracture requiring further characterization 2
• Patient develops neurological deficits (weakness, saddle anesthesia, bowel/bladder dysfunction) 1, 2
• Severe or progressive neurological symptoms emerge 1
• Plain films are negative but clinical suspicion remains high with persistent severe pain 1

Why This Patient Cannot Be Managed Without Imaging

The standard recommendation against routine imaging in nonspecific low back pain does not apply here 1:

• The absence of weakness does NOT exclude fracture—neurological deficits indicate cord compression, not simple fracture 2
• Midline tenderness in a patient on chronic steroids after trauma has high clinical significance for vertebral compression fracture 2
• Delayed diagnosis of vertebral fracture can lead to progressive collapse, neurological compromise, and increased morbidity 1

Additional Critical Management Considerations

Stress-dose glucocorticoid coverage:

• While evaluating the back pain, recognize that trauma represents physiological stress requiring increased glucocorticoid dosing in patients with Addison's disease 3, 4
• The patient's baseline prednisone dose provides only replacement therapy, not stress coverage 3, 4
• Failure to provide stress-dose steroids during acute illness or trauma can precipitate adrenal crisis (hypotension, shock, volume depletion) 3, 4

Common Pitfalls to Avoid

• Do not apply the "no routine imaging" guideline to patients with glucocorticoid-induced osteoporosis risk—this is a specific exception clearly outlined in guidelines 1
• Do not assume absence of neurological deficit means no fracture—compression fractures commonly present with pain alone initially 2
• Do not forget stress-dose steroid coverage while focusing on the orthopedic injury—this patient has two simultaneous high-risk conditions 3, 4
• Do not delay imaging pending "conservative management"—the presence of risk factors mandates early evaluation 1