This older patient has acute back pain consistent with vertebral compression fracture (VCF).  Acute VCF commonly occurs from minor trauma, such as lifting, twisting, coughing, or falling from standing height.  Pain is typically localized to the midline, although it can radiate to the flank or upper abdomen.  Pain often worsens with movement, coughing, or straining and may persist at night.  Examination typically demonstrates vertebral point tenderness; spinal cord or nerve root compression is rare, and patients usually do not have neurologic deficits.

VCF is most commonly due to decreased bone density from osteoporosis.  The risk is greatest in postmenopausal women and men age >65, such as this patient.  Other etiologies include osteomalacia, vertebral osteomyelitis, malignancy with bone metastases, metabolic abnormalities, and trauma.

The diagnosis is usually established with plain x-ray of the spine; MRI or CT scan are also effective if the diagnosis is uncertain or underlying malignancy is likely.  Imaging commonly identifies additional asymptomatic compressions.  Initial evaluation should also include screening studies to identify additional contributing factors (eg, hyperthyroidism, hyperparathyroidism, vitamin D deficiency).  DXA should also be obtained to guide chronic management.

(Choice A)  Apophyseal joint arthritis can occur in spondyloarthropathy (eg, ankylosing spondylitis), which typically presents with chronic, progressive pain that is worse at night and with prolonged rest; symptoms usually begin at age <40.

(Choice B)  Degenerative disc disease can cause low back pain, but the pain is usually chronic, worsens with activity, and is relieved with rest.  Disc degeneration can also lead to acute disc herniation, but this typically presents with acute lumbosacral radiculopathy (ie, pain radiating in a dermatomal distribution) because most herniations are posterolateral.  Vertebral point tenderness is more consistent with VCF.

(Choice C)  Ligamentous back sprain can occur following exertion.  However, the pain is usually relieved with rest, and tenderness would be seen in the paraspinal tissues rather than at the midline (over the vertebra).

(Choice E)  Nerve root demyelination (eg, Guillain-Barré syndrome) presents with paresthesia, weakness, and absent deep tendon reflexes corresponding to the affected nerve root.  Although back pain may be present due to nerve root inflammation, it typically is not associated with focal vertebral (bone) tenderness.

Educational objective:
Acute vertebral compression fracture can be caused by twisting, lifting, or other minimal trauma and presents with back pain and vertebral point tenderness.  It typically occurs in patients with osteoporosis or other conditions associated with decreased bone mineral density.