Should I refer an elderly female patient with a history of osteoporosis and previous lumbar fracture, presenting with pain at a higher level without neurological deficits, to a hospital for further evaluation and management?

Should This Patient Be Referred to a Hospital?

No, this elderly female patient with a history of osteoporosis and previous lumbar fracture presenting with pain at a higher thoracic level without neurological deficits does not require hospital referral and should be managed in the outpatient setting with urgent MRI and appropriate medical therapy. 1

Immediate Outpatient Diagnostic Workup

Order an MRI of the thoracic and lumbar spine without IV contrast immediately to identify the new fracture level, assess for multiple acute fractures, and exclude pathologic causes. 1 This is the single most important diagnostic test and provides comprehensive information in one study, including:

• Identification of acute versus chronic fractures through bone marrow edema on fluid-sensitive sequences 1, 2
• Detection of multiple concomitant fractures, which occur in 26% of patients presenting with symptomatic osteoporotic vertebral fractures 2
• Distinction between benign osteoporotic and pathologic fractures 1
• Assessment of spinal canal compromise 1

The absence of neurological deficits is the critical factor that makes outpatient management appropriate. 3, 1 Neurologic deficits such as motor weakness, sensory changes, or bowel/bladder dysfunction would require urgent surgical consultation and hospital referral. 1, 4

Important Clinical Caveat About Pain Location

Do not rely on the patient's pain location to determine fracture level. In a study of 51 patients with osteoporotic vertebral fractures, 80% of patients with thoracic fractures (T8-T12) reported only lumbar pain rather than thoracic pain. 5 The location of fracture and patient's pain report were not related (Kappa=0.046). 5 This means your patient's "higher level" pain may not accurately reflect where the new fracture is located, reinforcing the need for complete thoracic and lumbar spine imaging. 5

Baseline Laboratory Evaluation

Obtain the following labs to identify secondary causes of osteoporosis and guide treatment: 3, 6

• Complete blood count, erythrocyte sedimentation rate, C-reactive protein 1, 6
• Serum calcium, albumin, phosphate, alkaline phosphatase 3, 1
• Creatinine and thyroid-stimulating hormone 3, 1, 6
• 25-hydroxyvitamin D level 1, 6

Immediate Medical Management (While Awaiting MRI)

Initiate conservative pain management immediately: 6

• Start acetaminophen as first-line analgesia, avoiding NSAIDs given advanced age and potential cardiovascular/renal risks 6
• Consider short-term opioids if needed, but use cautiously due to fall risk 1, 6
• Avoid prolonged bed rest, as this accelerates bone loss, muscle weakness, and increases risk of deep venous thrombosis 1, 6
• Begin gentle range-of-motion exercises within the first few days 6

Osteoporosis Treatment Initiation

Start pharmacological therapy for osteoporosis immediately without waiting for MRI results: 6

• Initiate oral bisphosphonate therapy (alendronate 70 mg weekly or risedronate 35 mg weekly), which reduces vertebral fractures by 47-48% 6
• Prescribe calcium 1000-1200 mg/day (diet plus supplementation) and vitamin D 800 IU/day 6
• Consider calcitonin for the first 4 weeks to provide clinically important pain reduction 1

When Hospital Referral IS Required

Red flags that would necessitate immediate hospital referral include: 1

• Any neurological deficits (motor weakness, sensory changes, bowel/bladder dysfunction) 1, 4
• Constitutional symptoms such as fever, weight loss, or night sweats suggesting infection or malignancy 1
• Severe pain preventing ambulation despite adequate analgesia 1

Follow-Up Plan

Schedule outpatient follow-up within 1-2 weeks to review MRI results and adjust management accordingly. 3 If MRI confirms new acute fracture without complications, continue conservative management for 6-8 weeks with close monitoring. 1 Consider referral to an osteoporosis specialist or fracture liaison service for comprehensive secondary fracture prevention. 3

The high risk of subsequent fractures (20% within 12 months) makes systematic follow-up essential. 1, 2 Implement comprehensive fall prevention strategies and early postfracture physical training focusing on muscle strengthening and balance. 6