What is the best course of treatment and management for an elderly female patient with reduced bone density, moderate thoracic spondylosis, and marked scoliotic deformity after a motor vehicle accident?

Management of Elderly Female Post-Motor Vehicle Accident with Reduced Bone Density and Spinal Deformity

This patient requires immediate DEXA scan confirmation of bone density status and initiation of osteoporosis treatment, but does not require orthopedic referral for the scoliosis or spondylosis given the absence of acute fractures, neurological deficits, or pain requiring surgical intervention. 1, 2

Immediate Diagnostic Priority: DEXA Scan

You must obtain a formal DEXA scan of the lumbar spine and bilateral hips within the next 1-2 weeks to quantify bone mineral density and guide treatment decisions. 1, 3

• Plain radiographs showing "reduced bone density" are insufficient for diagnosis or treatment planning—they cannot accurately quantify BMD and miss up to 30% of osteoporosis cases until 30-40% of bone mass is already lost 1, 3
• The ACR Appropriateness Criteria designate DXA of lumbar spine and hips as "usually appropriate" (rating 9/9) for initial imaging in suspected osteoporosis in patients ≥50 years 1
• Critical caveat: Given her marked scoliosis (31-degree Cobb angle) and advanced lumbar spondylosis, the lumbar spine DEXA may be spuriously elevated 1, 4
  • If more than two lumbar vertebral levels show artifactual elevation from degenerative changes, exclude the entire lumbar spine and rely on hip measurements 1
  • Consider adding forearm DEXA if hip measurements are unreliable—forearm scanning detects osteopenia/osteoporosis in 41.2% of cases missed by hip alone in patients with spinal deformity 4

Treatment Initiation Based on DEXA Results

If T-score ≤ -2.5 (Osteoporosis):

Start pharmacological therapy immediately with oral bisphosphonates as first-line treatment. 2, 5

• Alendronate 70 mg once weekly is the standard first-line agent, demonstrating 2.8% increase in lumbar spine BMD and 1.9% increase in femoral neck BMD at one year in elderly patients 5
• Concurrent supplementation is mandatory: Calcium 1,200 mg daily and vitamin D 800 IU daily (target serum 25-OH vitamin D ≥20 ng/mL) 2, 3
• Consider preoperative teriparatide instead of bisphosphonates if any future spinal instrumentation is anticipated, as it reduces screw loosening and improves fusion rates (Grade B recommendation) 1

If T-score between -1.0 and -2.5 (Osteopenia):

Calculate FRAX score to determine if pharmacological treatment is warranted. 2

• Treat with bisphosphonates if 10-year hip fracture risk ≥3% OR major osteoporotic fracture risk ≥20% 2
• If FRAX scores below treatment thresholds, implement aggressive non-pharmacological measures:
  • Weight-bearing exercise program 2
  • Smoking cessation and alcohol limitation to ≤2 drinks daily 2
  • Fall prevention assessment with home safety evaluation 2
  • Calcium 1,200 mg and vitamin D 800 IU daily 2

Management of Scoliosis and Spondylosis

No orthopedic or neurosurgical referral is needed for the spinal deformity at this time. The imaging shows:

• 31-degree thoracolumbar scoliosis (mild-moderate range; surgery typically considered at >45-50 degrees in adults)
• Advanced degenerative changes but preserved vertebral alignment
• Most importantly: No acute fractures, no compression fractures, no spondylolisthesis, no neurological compromise [@patient imaging results@]

Conservative Management Approach:

• Physical therapy focused on core strengthening, posture training, and maintaining spinal flexibility 2
• Short-term NSAIDs (≤7-10 days) for pain if needed, given low risk of adverse effects with brief use 1, 2
• Avoid long-term high-dose NSAIDs given age and potential GI/renal risks 1

Indications for Future Referral (Monitor for These):

• Development of progressive neurological deficits
• Intractable pain unresponsive to conservative management
• Documented curve progression >5 degrees on serial imaging
• Development of compression fractures

Additional Vertebral Fracture Assessment

Add DXA vertebral fracture assessment (VFA) at the time of the DEXA scan. 1

This patient meets multiple high-risk criteria for VFA:

• Female ≥70 years 1
• Reduced bone density on plain films 1
• Post-trauma setting (MVA) 1

VFA detects clinically silent vertebral fractures in up to 67% of cases, and a single vertebral fracture is the strongest predictor of future fractures independent of BMD 1

Follow-Up Imaging Schedule

• If osteoporosis diagnosed and treatment initiated: Repeat DEXA in 1-2 years to assess treatment response 1, 3
• If osteopenia without treatment: Repeat DEXA in 2-3 years 3
• Hip and forearm measurements should be used for longitudinal monitoring given the unreliability of lumbar spine measurements in the setting of her degenerative changes 1, 4

Critical Pitfalls to Avoid

• Do not delay DEXA testing—plain film findings of "reduced bone density" already indicate significant bone loss requiring quantification 1, 3
• Do not rely solely on lumbar spine DEXA values in this patient with advanced spondylosis and scoliosis, as they will likely overestimate true BMD 1, 4
• Do not assume the MVA caused the scoliosis or spondylosis—these are chronic degenerative findings that predate the accident [@patient imaging results@]
• Do not over-treat the spinal deformity—the absence of acute fractures, pain, or neurological deficits means conservative management is appropriate 2