What is the appropriate management for a patient with lumbar pain following a history of trauma or fall?

Management of Lumbar Pain Following Trauma or Fall

For patients with lumbar pain and a history of trauma or fall, obtain plain radiographs (anteroposterior and lateral views) as the initial imaging study, followed by CT or MRI if radiographs are negative but clinical suspicion remains high, particularly in patients with osteoporosis, steroid use, age >65 years, or neurologic symptoms. 1

Initial Clinical Assessment

Immediately evaluate for "red flags" that indicate serious underlying pathology requiring urgent intervention 1:

• Progressive neurologic deficits (motor or sensory loss, new urinary retention/incontinence) 1, 2
• Severe or worsening symptoms despite initial management 1
• Risk factors for fracture: age >65 years, known osteoporosis, chronic steroid use 1
• High-energy mechanism or significant trauma relative to age 1, 2
• Midline tenderness over the lumbar spine 1
• History of cancer (strongest predictor of vertebral malignancy) 1

Imaging Algorithm

Initial Imaging

Plain radiographs (AP and lateral views) are the appropriate first-line study for patients with trauma history and suspected vertebral compression fracture 1. Upright radiographs provide functional information about axial loading and are particularly useful in patients with osteoporosis or steroid use 1.

Critical limitation: Radiographs have poor sensitivity (67-82% for lumbar fractures) and require at least 50% bone erosion before changes become visible 1.

Advanced Imaging Indications

Proceed immediately to CT or MRI without waiting for radiographs in these scenarios 1:

• Suspected cauda equina syndrome (urinary retention, saddle anesthesia, bilateral leg weakness) 1, 2
• Progressive neurologic deficits 1
• High clinical suspicion despite negative radiographs 1

CT lumbar spine without contrast is indicated when 1:

• Radiographs are negative but fracture remains suspected (sensitivity 94-100% for thoracolumbar fractures) 1
• Detailed assessment of bony integrity and fracture extent is needed 1
• Patient cannot undergo MRI 1

MRI lumbar spine without IV contrast is the preferred study when 1:

• Neurologic deficits are present (radiculopathy, myelopathy) 1
• Determining fracture acuity (bone marrow edema indicates acute injury) 1
• Assessing spinal canal compromise from displaced/retropulsed fractures 1
• Distinguishing benign from pathologic fractures (convex posterior vertebral body border, extension into posterior elements, abnormal marrow signal suggest malignancy) 1
• Suspected ligamentous injury (CT and radiographs miss purely ligamentous injuries) 3

Treatment Approach

Immediate Management

NSAIDs are first-line pharmacologic treatment 4, 5, 2:

• Ibuprofen 400 mg every 4-6 hours as needed (do not exceed 3200 mg daily) 4
• Use the lowest effective dose for shortest duration 4

Avoid bed rest - patients should remain as active as tolerated 1, 5, 6. There is strong evidence that bed rest is less effective than staying active for acute low back pain 1.

Conservative Management (if no red flags)

Nonpharmacologic interventions are first-line 5, 2:

• Activity modification with gradual return to usual activities 1, 6
• Heat therapy (good evidence of benefit) 6
• Physical therapy if symptoms persist beyond 2-4 weeks 1, 7
• Patient education on favorable prognosis (high likelihood of substantial improvement within first month) 1

When to Escalate Care

Obtain MRI and consider specialist referral if 1:

• Symptoms persist beyond 4-6 weeks despite conservative therapy 1, 5
• New or progressive neurologic symptoms develop 1
• Radiculopathy persists and patient is candidate for epidural steroid injection or surgery 1

Critical Pitfalls to Avoid

Do not rely solely on radiographs in high-risk patients - they miss 18-33% of lumbar fractures and cannot visualize soft tissue or nerve root compression 1, 3. In elderly patients with osteoporosis or those on chronic steroids, proceed directly to CT or MRI if clinical suspicion is high despite negative radiographs 1.

Do not delay imaging when red flags are present - delayed diagnosis of cauda equina syndrome, infection, or malignancy with spinal cord compression leads to significantly worse outcomes 1.

Do not order routine imaging in the absence of red flags - for uncomplicated mechanical low back pain, imaging within the first 4-6 weeks does not improve outcomes and increases costs 1, 5, 6.