What is the diagnosis and treatment for a patient with back pain, X-ray findings of anterior wedging of the L2 vertebral body and vertebral collapse, and DEXA (Dual-Energy X-ray Absorptiometry) scan results indicating low bone density with a femur neck T-score of -2.3 and lumbar T-score of -2.2?

Diagnosis: Osteoporotic Vertebral Compression Fracture with Underlying Osteoporosis

This patient has an osteoporotic vertebral compression fracture at L2 with confirmed osteoporosis by DEXA criteria (T-scores of -2.3 at femoral neck and -2.2 at lumbar spine), requiring immediate initiation of pharmacologic treatment with bisphosphonates as first-line therapy. 1, 2

Diagnostic Confirmation

The diagnosis is established by three key findings:

• T-score ≤ -2.5 at any site establishes osteoporosis by WHO criteria 1, and while this patient's scores are -2.3 and -2.2 (technically osteopenia range), the presence of a fragility fracture automatically upgrades the diagnosis to osteoporosis regardless of T-score 3, 4

• X-ray findings of anterior wedging and vertebral collapse at L2 represent a low-energy vertebral compression fracture, the most common type of osteoporotic fragility fracture 4, 5, 6

• Vertebral compression fractures are the hallmark of osteoporosis and indicate the patient is at substantial risk for additional fractures 7, 6

Critical Clinical Context

The presence of a vertebral fracture is the strongest predictor of future fractures and mandates immediate treatment 8, 3. This is particularly important because:

• Approximately two-thirds of vertebral compression fractures go undiagnosed and untreated, representing a major missed opportunity 5, 7

• Mortality after vertebral fracture is 22.4% at 1 year, 32.7% at 2 years, and 49.4% at 4 years 8

• Prior vertebral fracture patients have significantly elevated risk for subsequent fractures 4, 6

Immediate Treatment Algorithm

Step 1: Initiate Pharmacologic Therapy

Start oral bisphosphonates as first-line treatment 1, 2:

• Alendronate 70 mg once weekly (preferred option) 1, 2
• Alternative: Risedronate 35 mg once weekly or 150 mg once monthly 1
• Alternative: Ibandronate 150 mg once monthly 1

Bisphosphonates reduce vertebral fractures by 48% and hip fractures significantly 2. In patients with existing vertebral fractures, alendronate reduces the risk of new vertebral fractures from 15.0% to 7.9% (47% relative risk reduction) 2

Step 2: Alternative if Bisphosphonates Contraindicated

Denosumab 60 mg subcutaneously every 6 months if oral bisphosphonates are not tolerated or contraindicated 1:

• Reduces vertebral fractures by 68%, hip fractures by 40%, and non-vertebral fractures by 20% 1
• Critical warning: Must transition to bisphosphonate if denosumab is discontinued to prevent rebound bone loss 3

Step 3: Consider Anabolic Therapy for Very High Risk

If this patient has additional high-risk features (recent fracture, multiple fractures, very low T-scores), consider anabolic agents first 4:

• Teriparatide, abaloparatide, or romosozumab 4
• Teriparatide increases BMD, induces earlier and more robust fusion, and may improve outcomes 8
• Must be followed by antiresorptive therapy 4

Essential Concurrent Interventions

Nutritional Supplementation (Required Before/With Pharmacologic Treatment)

• Calcium 1000-1200 mg daily (in addition to dietary intake) 3, 1, 9
• Vitamin D 800-1000 IU daily 3, 1, 9
• Check serum vitamin D3 level; if <20 ng/mL, this predicts increased risk of adverse events 8

Non-Pharmacologic Measures

• Muscle resistance exercises (squats, push-ups) 4
• Balance exercises (heel raises, standing on one foot) 4
• Fall prevention strategies 3, 1
• Smoking cessation and limited alcohol consumption 3, 1, 9

Acute Fracture Management

For the current L2 vertebral compression fracture with back pain:

• Pain management with analgesics 6
• Consider bracing for symptom relief 6
• Physical therapy when appropriate 6
• Kyphoplasty or vertebroplasty may be considered if conservative management fails to provide adequate symptom relief 6

Monitoring Strategy

• Repeat DEXA scan in 1-2 years on the same machine using the same protocol 8, 1
• Compare absolute BMD values, not T-scores or Z-scores 3
• Changes exceeding the Least Significant Change (LSC) are considered clinically meaningful 3
• A significant change in BMD is ≥1.1% 1

Additional Diagnostic Considerations

Vertebral fracture assessment (VFA) imaging should be performed 8, 3:

• Particularly important in patients over 65 years 8, 3
• Can identify additional asymptomatic vertebral fractures 8
• Use Genant visual semiquantitative method for classification 8

If fracture appearance is atypical or there is doubt about the diagnosis:

• Obtain MRI without contrast to evaluate for malignancy or determine if fracture is acute vs chronic 8, 6
• MRI is the modality of choice for determining fracture age 6

Common Pitfalls to Avoid

• Do not delay treatment waiting for "worse" T-scores - the presence of a fragility fracture establishes the diagnosis and treatment indication regardless of DEXA results 3, 4

• Do not miss the diagnosis - two-thirds of vertebral compression fractures are not accurately diagnosed, leading to untreated osteoporosis 5, 7

• Do not forget to evaluate for secondary causes of osteoporosis (glucocorticoid use, inflammatory conditions, malabsorption, endocrine disorders) 4, 9

• Do not stop denosumab without transitioning to bisphosphonate - this causes rebound bone loss 3