What is the suspected diagnosis for a patient with severe back pain after a fall from a ladder?

Suspected Vertebral Fracture

In a 56-year-old patient with severe back pain after falling from a ladder, you should strongly suspect a vertebral fracture, particularly of the thoracolumbar spine, which is the most common site of injury from falls. 1

Clinical Context and Risk Factors

This patient meets multiple high-risk criteria for clinically significant thoracolumbar spine injury:

• High-risk mechanism of injury (fall from height greater than standing) 1, 2
• Age ≥56 years (the criteria threshold is ≥60 years, but this patient is close and falls are a major cause of spinal injury in this age group) 1
• Severe back pain following trauma 1

Falls from height cause a substantial proportion of spinal injuries, second only to motor vehicle accidents 1. The thoracolumbar junction (T12-L2) is particularly vulnerable to fracture from axial loading mechanisms that occur during falls 1.

Key Diagnostic Considerations

Immediate Assessment Priorities

You must evaluate for:

• Neurologic deficits including motor weakness, sensory changes, or bowel/bladder dysfunction, which would indicate potential spinal cord injury 1, 2
• Altered mental status or intoxication, which would necessitate imaging clearance regardless of examination findings 1
• Presence of distracting painful injuries that could mask spinal symptoms 1

Imaging Approach

CT is the gold standard and preferred initial imaging modality for suspected vertebral fracture in trauma patients 1, 3:

• CT has 94-100% sensitivity for detecting thoracic spine fractures 3
• CT can be performed rapidly and excellently depicts complex vertebral structures 1
• Reformatted images from chest/abdomen/pelvis CT (if obtained for other injuries) are effective and radiation-dose sparing 3
• The entire spine should be imaged because 20% of trauma patients with one spinal fracture have noncontiguous fractures at other levels 1, 3

Plain radiographs are inadequate as the sole imaging modality 1, 3:

• Radiographs have lower sensitivity than CT for fracture detection 1
• They may miss significant thoracic spine injuries, particularly in the upper thoracic region 3
• Negative radiographs in high-risk patients should be followed by CT 1

When to Add MRI

MRI should be obtained if there is 1, 3:

• Clinical suspicion for spinal cord injury or neurologic deficit 4, 3, 5
• Concern for ligamentous instability 3, 5
• Nerve root compression 3
• Neurologic findings that are disproportionate to CT findings 5

MRI is complementary to CT and provides superior visualization of soft tissues, spinal cord, ligaments, and intervertebral discs 2, 3, 5.

Critical Pitfalls to Avoid

• Do not rely solely on physical examination in patients meeting high-risk criteria—a prospective study found 98.9% sensitivity for thoracolumbar injury using criteria of positive examination, high-risk mechanism, or age ≥60 years 1
• Do not miss multilevel fractures—always image the entire spine when one fracture is identified 1, 3
• Do not delay imaging in patients with neurologic deficits—delayed diagnosis is associated with poorer outcomes 1, 5
• Maintain spinal motion restriction by manually stabilizing the head and minimizing movement until fracture is excluded 1, 2

Additional Differential Considerations

While vertebral fracture is the primary concern, also consider:

• Spinal cord injury without fracture (though less common in adults) 2
• Ligamentous injury causing instability even without fracture 3, 5
• Soft tissue injuries including muscle strains, though these would not typically cause "severe" pain after significant trauma 6