What are the treatment options for a lump on the lower back after a fall?

Management of a Lump on the Lower Back After a Fall

For a lump on the lower back following a fall, obtain plain radiographs immediately, and if negative but clinical suspicion remains high for fracture, proceed directly to CT imaging of the spine—do not rely on radiographs alone as they miss many vertebral fractures. 1

Initial Clinical Assessment

Immediately evaluate for red flags that indicate serious underlying pathology requiring urgent intervention 2, 3:

• Neurological deficits: Check for motor weakness, sensory loss, reflex changes, or bowel/bladder dysfunction suggesting cauda equina syndrome 2, 3
• Progressive symptoms: Worsening pain or new neurological findings 2
• Trauma history: The mechanism of fall is critical—falls from height significantly increase fracture risk 4

The presence of a palpable lump after trauma strongly suggests underlying bony injury, soft tissue hematoma, or both 1.

Imaging Strategy

Start with plain radiographs of the thoracic and lumbar spine as the initial imaging modality 2. However, recognize a critical limitation: radiographs have poor sensitivity for detecting vertebral compression fractures and end-plate injuries 1.

If radiographs are negative but clinical suspicion remains high (palpable lump, significant trauma mechanism, persistent pain):

• Proceed immediately to CT imaging of the thoracic and lumbar spine 1
• CT is superior for detecting subtle compression fractures, end-plate defects, and posterior column injuries that are invisible on plain films 1, 4

Consider MRI (preferred over CT when available) if 2, 3:

• Neurological symptoms are present
• Soft tissue injury assessment is needed
• The patient may be a surgical candidate
• Spinal cord or nerve root compression is suspected

A case report demonstrates this principle: a 29-year-old with normal radiographs after a fall was found on CT to have multilevel end-plate compression defects with anterior wedging and bone fragment retropulsion at L1 1.

Fracture Patterns to Anticipate

Falls commonly produce specific injury patterns 4:

• Burst fractures (most common, 38% of cases) typically occur at the thoracolumbar junction 4
• Compression fractures (26% of cases) also favor the thoracolumbar region 4
• Multiple-level fractures occur in 32% of patients, with 29% at non-continuous levels—scan the entire spine 4
• Higher falls increase the likelihood of burst fractures and multi-level involvement 4

Rule Out Soft Tissue Sarcoma

While less likely in acute trauma, if the lump persists or enlarges beyond expected healing timeframes (2-4 weeks), consider soft tissue pathology 2:

• Obtain urgent ultrasound (within 2 weeks) to assess for soft tissue mass if the lump is unexplained and increasing in size 2
• Most soft tissue lumps are benign lipomas, but atypical lipomatous tumors tend to be larger, deep-seated, and occur in the lower limb/back region 2
• If ultrasound findings are uncertain and clinical concern persists, refer for specialist evaluation 2

Conservative Management for Confirmed Fractures

For osteoporotic compression fractures without neurological deficits 2:

• Medical management is first-line for the first 3 months 2
• Prescribe acetaminophen or NSAIDs as first-line analgesics, assessing cardiovascular and GI risk before NSAIDs 2, 3
• Advise activity as tolerated—prolonged bed rest is not recommended 2, 3
• Consider skeletal muscle relaxants for short-term relief if needed 3

Percutaneous vertebral augmentation (vertebroplasty/kyphoplasty) is reasonable for 2:

• Severe pain refractory to 3 months of conservative therapy 2
• Spinal deformity or pulmonary dysfunction 2
• Pathologic fractures from malignancy with severe pain 2

Surgical Indications

Immediate surgical consultation is mandatory for 2:

• Frank spinal instability
• Neurological deficits (motor weakness, sensory loss, cauda equina syndrome)
• Progressive neurological deterioration despite conservative management

Critical Pitfalls to Avoid

1. Do not rely solely on negative radiographs after significant trauma—CT is essential when clinical suspicion is high 1
2. Do not miss multi-level fractures—scan the entire spine, as 29% occur at non-continuous levels 4
3. Do not delay imaging if red flags are present—serious pathology requires prompt diagnosis 2, 3
4. Do not dismiss a persistent or enlarging lump as simple trauma—consider soft tissue pathology if it doesn't resolve appropriately 2

Follow-Up

Reassess at 4-6 weeks if symptoms persist despite conservative management 2, 3. Patients with confirmed fractures should be counseled about the risk of subsequent fractures and the importance of fall prevention and osteoporosis treatment 2.