What is the diagnosis for a patient presenting with acute back pain and radiographic evidence of vertebral compression fracture in the context of osteoporosis?

Diagnosis: Acute Osteoporotic Vertebral Compression Fracture

This patient has an acute osteoporotic vertebral compression fracture, confirmed by the combination of acute back pain onset, radiographic evidence of vertebral collapse with anterior wedging, and DXA T-scores indicating osteoporosis. 1

Diagnostic Criteria Met

The diagnosis is established through three key findings:

• Radiographic confirmation: X-ray demonstrates anterior wedging and vertebral collapse, which are pathognomonic features of vertebral compression fracture 1
• Clinical presentation: Acute onset back pain is the hallmark symptom, occurring in the majority of symptomatic vertebral compression fractures 2, 3
• Bone density confirmation: DXA T-scores establish underlying osteoporosis as the etiology, distinguishing this from pathological fractures due to malignancy or infection 1

Key Diagnostic Considerations

Distinguishing Acute from Chronic Fractures

While the clinical scenario describes acute pain, it is critical to recognize that:

• 26% of patients with symptomatic vertebral fractures have concomitant (simultaneous) fractures at multiple levels 4
• 60% have previous vertebral fractures that may be visible on plain films 4
• MRI with STIR or fat-saturated T2-weighted sequences is the gold standard for distinguishing acute from chronic fractures, showing hyperintense signal (bone marrow edema) in acute fractures that typically resolves within 1-3 months 1

Common Pitfalls in Diagnosis

The correct diagnosis is made at the first clinical visit in only 43% of patients, with a mean diagnostic delay of 4.5 days 2. This occurs because:

• Pain location may not correspond to fracture site—radiation to flanks and anterior abdomen occurs in 66% of cases 2
• Associated symptoms can be misleading: nausea (26%), abdominal pain (20%), chest pain (13%) 2
• 46% of fractures occur spontaneously, and 30% of spontaneous fractures occur while in bed 2
• Plain radiographs may initially appear normal if performed very early; bone scanning may be necessary 2

When to Suspect Alternative Diagnoses

Additional imaging beyond plain radiography should be obtained when 1:

• Equivocal fractures or atypical-appearing vertebral bodies on initial imaging
• Known or suspected malignancy (sclerotic or lytic changes)
• Fever, elevated inflammatory markers, or immunocompromised state (consider vertebral osteomyelitis) 1
• Two or more mild deformities without moderate or severe deformities
• Suboptimal vertebral visualization on initial studies

Osteoporosis Despite "Better" T-Scores

Importantly, 38% of patients ≥65 years with vertebral fractures have osteopenia or normal BMD by T-score criteria alone 1. This means:

• A vertebral fracture itself establishes the diagnosis of osteoporosis regardless of T-score (per WHO criteria)
• The presence of a fragility fracture indicates treatment is warranted even with T-scores in the osteopenic range
• Mean femoral neck T-score in patients with vertebral fractures is only -1.4 1

Anatomical Pattern Recognition

Certain vertebrae are preferentially affected: T8, T12, L1, and L4 are the most common fracture sites 2. This patient's fracture location should be evaluated in this context.

Clinical Implications for Management

The diagnosis of acute osteoporotic vertebral compression fracture triggers:

• Immediate need for multimodal pain management (analgesics, possible bracing, physical therapy) 1, 3
• Evaluation for vertebral augmentation (vertebroplasty/kyphoplasty) if conservative management fails after 6 weeks to 3 months 1
• Initiation of osteoporosis pharmacotherapy to prevent future fractures 3
• Assessment for additional acute fractures throughout the thoracic and lumbar spine, given the 26% incidence of concomitant fractures 4