CC Back pain following a fall Jesse Degani

CC: Back pain following a fall Jesse Degani 2/24/2021 Diagnostic Radiology RAD 4001

Clinical History • HPI: 75 year old woman with PMH depression, HLD, hepatic steatosis, and asthma presents to the emergency room with moderate-to-severe back pain for three days following a fall from standing. The patient fell on her backside while walking after losing power in her room. No head trauma, no LOC. The patient also reports decreased PO intake due to nausea , vomiting, and decreased appetite of three days duration. Rest of ROS is negative. Primary: ABCDEs intact Vitals: Afebrile, HR 72, BP 128. 76, RR 18, Sp. O 2 98% Mc. Govern Medical School

Evaluation Physical Exam • General: in distress 2/2 to pain and GI symptoms • Skin: right elbow echymosses • HEENT: NCAT, pupillary exam wnl • CV: normal S 1/S 2, no murmurs, normal peripheral pulses • Abdomen: soft, non-tender, normal BS, no organomegaly • Pulm: CTA b/l • Neurologic: no focal deficits Labs • CBC: WBC = 11. 2, otherwise wnl • Creatinine = 0. 56 mg/d. L • BUN = 10 mg/d. L • AST/ALT = 46/25 units/L • Alk Phos 78 units/L • Lipase = 2866 units/L (H) • TSH = 0. 306 u. IU/m. L (L) • TB/DB = 2. 5 /0. 4 mg/d. L Mc. Govern Medical School

Findings 1. Acute, comminuted L 1 burst fracture 2. Crush & wedge deformities 3. 70% anterior vertebral body height loss, 20% posterior asymmetric loss 4. Retropulsion 5. Arterial calcifications 6. Low Bone Mineral Density Initial Imaging – Sagittal CT Slide 22 Slide 24 Slide 26 Slide 28 Thoracolumbar CT w/o contrast - Sagittal view Mc. Govern Medical School Slide 30 Slide 32

Findings 1. Acute, comminuted L 1 burst fracture Initial Imaging Thoracolumbar CT w/o contrast - Axial view Mc. Govern Medical School

ACR Appropriateness Mc. Govern Medical School

Normal Spinal Anatomy Thoracolumbar MRI w/o contrast – T 2 – Sagittal view Mc. Govern Medical School

Initial Imaging Findings 1. Moderate retropulsion of posterior cortex 2. The changes cause moderate-to-severe canal stenosis 3. Disruption of anterior longitudinal, posterior longitudinal, and ligamentum flavum 4. No 2 nd level fracture found in the rest of the spine Thoracolumbar MRI w/o contrast – T 2 Weighted – Sagittal view Mc. Govern Medical School

Highlight and summarize key imaging findings Findings 1. Acute, comminuted L 1 burst fracture 2. Retropulsion resulting in spinal stenosis 3. Crush & wedge deformities 4. 70% anterior vertebral body height loss 5. Arterial calcifications 6. Low Bone Mineral Density Other relevant findings: 1) Otherwise normal cervicothoracic spine, no secondary vertebral fracture 2) MRCP and RUQ unremarkable, lipase resolved and no diagnosis of pancreatitis was made Mc. Govern Medical School

Genant classification of vertebral fractures Genant Scale • Mild: up to 20 -25% • Moderate: 25 -40% • Severe: >40%

Procedure Performed – PSIF from T 12 – L 2 • Goal is to restrict spinal motion and remove the degenerated disc in order to relieve symptoms. • All spinal fusion procedures involve placement of a bone graft between the damaged vertebral discs. CT Abdomen w/ contrast - Axial view https: //www. jnjmedicaldevices. com/en-US/treatment/spine/posterior-lumbar-fusion Mc. Govern Medical School

Post-op Imaging Findings 1. PSIF from T 12 – L 2 2. Unilateral left lag screw at L 1 3. Cement augmentation 4. Residual 50% change in anterior vertebral height, compared with 70% pre-op Lateral Thoracolumbar XR Posterior Thoracolumbar XR Mc. Govern Medical School

Discussion Pathophysiology & Prognosis of VCFs • Loss of bone mineral density (BMD). • Morbidity associated with these fractures includes decreased physical function and social isolation, which have a significant Temporality Etiology impact on the patient's overall quality of life Acute • • Cortical breaking Impaction of the trabeculae Chronic Osteoporotic Pathological Trauma Mc. Govern Medical School

Discussion Patients can have both malignancy and osteoporosis. How can we differentiate pathologic fractures from osteoporotic? Features that favor pathological fractures are: • • fracture with bony destruction (on CT) convex bulging (not retropulsion) of the posterior vertebral cortex into the spinal canal epidural or paraspinal mass other vertebral metastases Mc. Govern Medical School

Cost Effectiveness Mc. Govern Medical School

Differential Diagnosis • Vertebral deformity differential: Osteoporotic fracture, posttraumatic deformity, degenerative remodeling, congenital anomaly, neoplastic deformity, and Paget's disease • Evident from imaging, the patient has low BMD. This likely contributed to the fracture despite the history of trauma (fall from standing). • VCFs are a common manifestation of an assortment of disease - ddx includes: • Age related osteoporosis, estrogen-deficiency osteoporosis, malignancy, infection, hyperparathyroidism, Paget’s disease, trauma Patient likely has a combination of age related and estrogen deficiency related osteoporosis. Mc. Govern Medical School

Final Diagnosis L 1 burst fracture with pre-operative loss of anterior vertebral height of 70%, and a post-op height loss of 50% Mc. Govern Medical School

Take Home Points / Teaching points • VCFs are a common manifestation of an assortment of disease, and considered to be an underdiagnosed cause of back pain. • Osteoporosis can coexist with cancer. • A vertebral deformity does not always represent a vertebral fracture, but a vertebral fracture is always a vertebral deformity Mc. Govern Medical School

References • https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 3591834/ • https: //www. jnjmedicaldevices. com/Evidence behind PSIF efficacy • https: //www. uptodate. com/contents/subacute-and-chronic-low-back-painsurgicaltreatment? search=posterior%20 spinal%20 fusion&source=search_result&selected. Title=2~150&usage_type=defaul t&display_rank=2#H 4 • https: //learningneurology. com/diagnostic-tests/approach-to-mri-spine/ • https: //www. uptodate. com/contents/subacute-and-chronic-low-back-pain-surgicaltreatment? search=posterior%20 spinal%20 fusion&source=search_result&selected. Title=2~150&usage_type=default&displ ay_rank=2#H 4 • https: //www. uptodate. com/contents/clinical-manifestations-diagnosis-and-evaluation-of-osteoporosis-inpostmenopausalwomen? search=osteoporosis&source=search_result&selected. Title=4~150&usage_type=default&display_rank=3#H 33290 78 Mc. Govern Medical School

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