What is the appropriate workup for an elderly female patient with a history of osteoporosis and a previous lumbar fracture, presenting with 3 days of pain similar to her previous fracture but at a higher level, without neurological deficits, numbness, tingling, or loss of urinary, bladder, or bowel function?

Workup for Suspected New Vertebral Compression Fracture

Obtain MRI of the lumbar spine without IV contrast immediately to identify the new fracture level, assess for additional acute fractures, and exclude pathologic causes. 1, 2

Imaging Strategy

MRI lumbar spine without IV contrast is the single most important diagnostic test and should be performed on all patients if not contraindicated, as it provides comprehensive information in one study 2:

• Identifies acute versus chronic fractures through bone marrow edema on fluid-sensitive sequences (STIR or T2-weighted with fat saturation) 1, 2
• Detects multiple fractures simultaneously - critical since 20% of patients develop another vertebral fracture within 12 months of the first 3, 4
• Distinguishes benign osteoporotic from pathologic fractures by evaluating for convex posterior vertebral body border, extension into posterior elements, and abnormal marrow signal patterns 1, 2
• Assesses spinal canal compromise from retropulsed fragments or posterior wall involvement 1

When to Add IV Contrast

Upgrade to MRI without and with IV contrast if 1:

• Clinical suspicion of underlying malignancy (history of cancer, constitutional symptoms)
• Concern for infection (fever, elevated inflammatory markers)
• Indeterminate findings on non-contrast sequences

Alternative if MRI Contraindicated

If MRI is contraindicated, obtain 1:

• CT lumbar spine without IV contrast for detailed fracture analysis and posterior column integrity
• Bone scan with SPECT/CT to evaluate fracture acuity if CT findings are equivocal 1

Initial Plain Radiographs

Anteroposterior and lateral radiographs of the lumbar spine are reasonable as an initial screening tool in patients with known osteoporosis, but should not delay or replace MRI 1, 5:

• Useful for assessing vertebral height loss and alignment
• Cannot reliably determine fracture acuity - approximately two-thirds of vertebral compression fractures are asymptomatic and may represent old fractures 5
• Cannot exclude additional acute fractures at other levels 2

Critical Red Flags Requiring Urgent Evaluation

Assess immediately for 5:

• Neurologic deficits (motor weakness, sensory changes, bowel/bladder dysfunction) - requires urgent surgical consultation
• Constitutional symptoms (fever, weight loss, night sweats) - suggests infection or malignancy
• History of malignancy - raises concern for pathologic fracture
• Progressive vertebral collapse on serial imaging - indicates instability

Laboratory Workup

Obtain baseline labs to assess for secondary causes and guide treatment 6:

• Complete blood count (infection, malignancy)
• Erythrocyte sedimentation rate and C-reactive protein (infection, inflammation)
• Serum calcium, phosphate, alkaline phosphatase (metabolic bone disease)
• Thyroid function tests (hyperthyroidism)
• 25-hydroxyvitamin D level (vitamin D deficiency)
• Consider parathyroid hormone if hypercalcemia present (hyperparathyroidism)

Common Pitfalls to Avoid

Do not assume pain is from the known old fracture - obtain new imaging if symptoms change or prior imaging is >3 months old 3:

• New pain at a different level strongly suggests a new fracture 2
• Patients with one vertebral fracture have 20% risk of another within 12 months 3, 4
• Women with severe vertebral fractures have 12.6 times the risk of new vertebral fractures 4

Do not rely on plain radiographs alone - they miss acute fractures and cannot distinguish acute from chronic 2, 5:

• MRI identifies unhealed fracture levels not evident on radiography 2
• Bone marrow edema on MRI is the gold standard for fracture acuity 1, 5

Do not delay osteoporosis pharmacotherapy while awaiting imaging results 3:

• Immediate initiation of bisphosphonates (ibandronate) or other antiresorptive therapy reduces risk of subsequent fractures 3
• Prolonged immobilization causes bone loss at 1% per week (50 times faster than age-related loss) 2

Next Steps After Diagnosis

Once new fracture is confirmed on MRI 3, 5:

• Conservative management for 6-8 weeks if neurologically intact with <20% height loss and no posterior wall retropulsion 3, 5
• Calcitonin for first 4 weeks provides clinically important pain reduction 3
• NSAIDs or opioids for pain control (use opioids cautiously due to fall risk) 3
• Avoid prolonged bed rest - causes rapid deconditioning and increased fracture risk 2, 3
• Consider vertebral augmentation only if severe pain persists after 3 months of conservative therapy preventing ambulation 2, 3