Should an elderly patient with osteoporosis, who underwent a bone marrow biopsy one week ago and now presents with severe back pain radiating to the right leg, undergo an X-ray?

Yes, this patient requires immediate X-ray imaging of the spine

An elderly patient with osteoporosis who develops severe back pain (8/10) with radicular symptoms four days after a bone marrow biopsy should undergo X-ray imaging of the spine as the initial study, followed by MRI if radiographs are negative or clinical suspicion remains high, because this presentation represents multiple red flags including acute/subacute pain, radiculopathy, and recent invasive procedure in a high-risk patient. 1

Clinical Red Flags Present

This patient exhibits several critical red flags that mandate imaging:

• Constant pain lasting >4 days that has progressed from pain-free status is a red flag requiring investigation 2
• Pain radiating to the right leg indicates potential nerve root compression or radiculopathy 2
• Severe pain intensity (8/10) in an osteoporotic patient suggests possible vertebral fracture 1
• Recent invasive procedure (bone marrow biopsy one week ago) raises concern for procedure-related complications including infection or fracture 3

Initial Imaging Approach

X-ray as First-Line Study

Plain radiographs of the spine (area of interest) are rated 9/9 (usually appropriate) as the initial imaging modality for suspected vertebral fracture in patients with osteoporosis presenting with acute or subacute back pain. 1

• X-rays can identify vertebral compression fractures, which are the most common clinical manifestation of osteoporosis 4
• Radiographs should include two views (frontal and lateral) of the symptomatic region 1
• This is appropriate even though the patient was recently pain-free, as osteoporotic fractures can occur with minimal trauma 5, 6

Important Caveat About Radiographs

Negative radiographs do not exclude serious pathology. 2 If X-rays are negative but symptoms persist or worsen, advanced imaging is mandatory.

If Radiographs Are Negative: Next Steps

MRI Without Contrast

If initial radiographs are negative but clinical suspicion remains high, MRI lumbar spine without IV contrast is rated 9/9 (usually appropriate) as the next imaging study. 1

• MRI can detect vertebral fractures not visible on plain films, including bone marrow edema indicating acute fracture 1
• MRI is superior for evaluating soft tissue complications, spinal cord compression, and nerve root involvement 2
• MRI can identify early discitis/osteomyelitis, which is a concern given the recent bone marrow biopsy 3

When to Add Contrast

MRI without and with IV contrast should be obtained if there is clinical suspicion for infection (discitis/osteomyelitis) or epidural abscess given the recent invasive procedure. 3

Red flags suggesting infection include:

• Fever or elevated inflammatory markers (CRP, ESR) 3
• Progressive neurological deficits 3
• Persistent nighttime pain unresponsive to rest 3

Differential Diagnosis to Consider

Vertebral Compression Fracture (Most Likely)

• Osteoporotic vertebral fractures are the earliest clinical manifestation of osteoporosis 4
• Can occur spontaneously or with minimal trauma in patients with established osteoporosis 5, 6
• The patient's pain-free status one week ago does not exclude fracture, as these can develop acutely 4

Procedure-Related Complications

• Discitis/osteomyelitis: Can develop after bone marrow biopsy, presenting with back pain and radicular symptoms 3
• Epidural hematoma or abscess: Rare but serious complications that can cause acute neurological symptoms 3

Nerve Root Compression

• Radicular pain to the right leg suggests L4-S1 nerve root involvement 2
• May be due to fracture fragment, disc herniation, or epidural process 2

Clinical Pitfalls to Avoid

• Do not delay imaging based on the assumption that pain is simply post-procedure discomfort, especially given the 4-day progression and severity 2
• Do not assume normal radiographs exclude pathology - proceed to MRI if clinical suspicion remains high 2, 1
• Do not miss infection - maintain high suspicion for discitis given the recent invasive procedure and obtain inflammatory markers 3
• Do not ignore progressive neurological symptoms - these require urgent MRI and potential surgical consultation 2

Immediate Management Considerations

• Obtain X-ray spine immediately (same day) 1
• Check inflammatory markers (CRP, ESR, WBC) to evaluate for infection 3
• Perform focused neurological examination documenting motor strength, sensation, and reflexes in lower extremities 2
• If radiographs show fracture, determine acuity (compare to any prior imaging if available) 1
• If radiographs are negative but symptoms persist, proceed directly to MRI without delay 1