Immediate Management of Acute Back Pain with Audible Click in a 60-Year-Old
This patient requires immediate evaluation for vertebral compression fracture given the audible click, age >60 years, and acute pain onset, which are red flags mandating early imaging rather than conservative management. 1
Initial Assessment Priority
Rule out compression fracture immediately – the combination of an audible "click" with sudden pain onset in a 60-year-old represents significant trauma and meets criteria for urgent imaging. 1 The thoracic spine is a common site for osteoporotic compression fractures, and age >65 years (this patient is approaching this threshold) is a specific risk factor requiring early imaging consideration rather than trial of conservative therapy. 1
Critical Red Flags to Assess Now
- Neurologic examination: Check for myelopathy signs (cord compression), radiculopathy, or cauda equina symptoms (bowel/bladder dysfunction, saddle anesthesia, progressive motor deficits). 1
- Trauma mechanism: Even minor trauma in older adults can cause fractures; an audible click suggests structural failure. 1
- Osteoporosis risk factors: Chronic steroid use, prior fractures, low body weight, smoking. 1
- Cancer history: Metastatic disease to spine. 1
Imaging Decision
Order MRI lumbar/thoracic spine immediately – do not wait for conservative management trial. 1 The ACR Appropriateness Criteria specifically state that patients with significant trauma or risk factors for compression fracture (age >65, osteoporosis) warrant early imaging. 1 MRI is preferred over plain radiographs because it visualizes vertebral marrow, cord compression, and soft tissue pathology. 2, 3
Plain radiographs miss early compression fractures and cannot assess spinal canal or neural elements. 3
Pain Management While Awaiting Imaging
Start intravenous acetaminophen 1000mg every 6 hours as first-line – this provides effective analgesia with the best safety profile in older adults. 1
Add NSAIDs cautiously if severe pain persists – consider ibuprofen 400-600mg or naproxen 500mg, but weigh gastrointestinal and cardiovascular risks carefully in this age group. 1 NSAIDs provide superior analgesia to acetaminophen alone but carry significant adverse event risk. 1
Avoid opioids initially – reserve for breakthrough pain only if acetaminophen and NSAIDs are insufficient, and use the lowest effective dose for the shortest duration. 1
Apply ice packs to the affected area – this is a reasonable adjunctive non-pharmacologic measure. 1
Activity Modification
Immobilize the spine temporarily – unlike uncomplicated mechanical back pain where activity is encouraged, suspected fracture requires protection until imaging confirms or excludes structural injury. 1 If compression fracture is confirmed, bracing may be indicated. 1
Absolutely avoid bed rest beyond what is necessary for severe pain – even with fracture concern, prolonged immobilization causes deconditioning. 1
Common Pitfalls to Avoid
- Do not treat this as simple mechanical back pain – the audible click changes the clinical picture entirely and elevates concern for fracture. 1
- Do not delay imaging for 4-6 weeks of conservative therapy – this approach applies only to patients without red flags. 1, 4
- Do not prescribe systemic corticosteroids – they provide no meaningful benefit for back pain and worsen osteoporosis. 1
- Do not order bone scan or CT myelography as initial imaging – these have no role in initial evaluation. 1
Next Steps Based on Imaging
If compression fracture confirmed: Refer to spine specialist for consideration of vertebroplasty/kyphoplasty, initiate osteoporosis treatment, ensure adequate calcium/vitamin D supplementation. 1
If no fracture but severe pain persists: Then transition to standard acute back pain management with NSAIDs, remaining active, heat therapy, and physical therapy. 1, 4
If myelopathy or progressive neurologic deficits: Urgent neurosurgical consultation. 1, 3