Back Pain OSCE - Vertebral Fracture

Case Overview

• Age/Sex: 60-year-old female
• Occupation: Retired schoolteacher
• Setting: Emergency department / urgent clinic after sudden onset severe back pain
• Chief complaint: "My back is killing me — I can't stand up straight."

Patient Script

Who I Am

I'm a 60-year-old retired schoolteacher who lives alone and has diabetes and osteoporosis.

What Brings Me In

I bent over to pick up a glass three days ago and felt a sudden, terrible pain in my lower back — it's been getting worse and I can't stand up properly.

My Story

Three days ago, while bending to pick up a glass from the kitchen floor, I felt a sudden sharp pain in my lower back and heard a small "crack" in my back. The pain was immediate and very severe. At first I tried to rest at home, but the pain has been constant since then and worse when I try to stand or walk. I can lie down and it's a bit better, but even turning in bed is painful. I can't stand up straight — I feel like I'm bending forward all the time. I have had osteoporosis for several years but stopped the tablets a while ago because they upset my stomach. I also have Type 2 diabetes and high blood pressure.

I haven't had fever, but I had a urinary tract infection a month ago that needed antibiotics. I had a lump removed from under my arm 12 years ago and was told it was benign, so I don't think I have cancer. I did fall off a stepladder six months ago but was fine then. I was prescribed a short steroid course for chest wheeze about a year ago, but I don’t take regular oral steroids — only inhalers for my COPD.

My Medical Background

• Past medical history: Type 2 diabetes mellitus (diagnosed 10 years ago), osteoporosis (diagnosed 6 years ago), hypertension, COPD (mild, on inhalers)
• Medications: Metformin 500 mg twice daily, long-acting insulin at night (name/dose withheld), lisinopril 10 mg daily, inhaled salmeterol/fluticasone, used to be prescribed alendronate but I stopped because it upset my stomach; occasional paracetamol for pain
• Allergies: None known
• Social: Lives alone, retired, former non-smoker, drinks 1–2 glasses of wine on weekends, ambulatory but unsteady on stairs at times
• Family history: Mother had a hip fracture in her 70s; no known breast cancer in family

What I Think & Worry About

• I think I must have broken my back because it was so sudden and bad.
• I'm worried I won't be able to look after myself at home and might need surgery.
• I expect you to give something to take the pain away and tell me why this happened.

If You Ask Me About Other Symptoms...

• Pain: The pain is sharp, central in my lower back, worse on standing and coughing, constant for 3 days.
• Leg symptoms: I have some numbness in my toes sometimes from my diabetes, but I don't have new weakness or sudden foot drop.
• Bowel/bladder: No urinary retention or incontinence; I still pass urine normally though I pass it a bit more often because of my diabetes.
• Fever/systemic: No fevers or sweats, no recent weight loss that I know of.
• Respiratory: I sometimes wheeze because of my COPD but I have no new shortness of breath today.
• Recent infections/cancer: UTI last month (treated), lump removed years ago was benign as far as I was told.

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Clinical Summary

Examination

• General: Alert, uncomfortable, sits leaning forward; appears in moderate to severe pain.
• Vitals: BP 150/85 mmHg, HR 98/min, RR 18/min, SpO2 97% on room air, Temp 36.8°C
• Inspection: Thoracolumbar kyphotic posture, reduced ability to straighten spine
• Palpation: Localised midline tenderness to percussion over T12–L1 region
• Movement: Severe pain on lumbar extension and standing; limited range of motion due to pain
• Neurological: Lower limb power 5/5 bilaterally, reflexes symmetrical (knee jerk and ankle jerk normal), sensation intact to light touch except for chronic distal reduced sensation in feet consistent with diabetic peripheral neuropathy; straight leg raise negative
• Gait: Antalgic, limited by pain but able to weight-bear slowly

Investigations

• Plain X-ray (thoracolumbar spine): Wedge compression fracture of L1 with approximately 30% anterior vertebral height loss, generalized osteopenia (consistent with osteoporosis)
• CT spine (if performed): No significant retropulsion into the canal, no obvious bony fragments causing canal compromise (supports stable compression fracture)
• MRI spine (if performed / if concern for cord compromise or malignancy): No cord compression or epidural mass; marrow signal changes at L1 consistent with acute fracture
• DEXA scan: T-score -2.8 at femoral neck (osteoporosis)
• Bloods: CBC: Hb 12.4 g/dL, WBC 7.8 x10^9/L, Platelets 250 x10^9/L (no leukocytosis)
• Inflammatory markers: ESR 18 mm/hr, CRP 4 mg/L (not markedly raised — against infective process)
• Metabolic: Calcium 9.2 mg/dL, Phosphate normal
• Vitamin D 25-OH: 12 ng/mL (deficient)
• Renal function: Creatinine 1.0 mg/dL, eGFR ~60 mL/min/1.73m^2
• HbA1c: 7.8% (suboptimal diabetic control)

Diagnosis

• Primary: Acute osteoporotic vertebral compression fracture at L1

  • Evidence: sudden onset severe focal back pain after minor bending event, point tenderness at T12–L1, plain X-ray demonstrating wedge compression with reduced anterior height, DEXA confirming osteoporosis, low vitamin D.

• Differentials:

  • Pathological vertebral fracture from metastatic disease — considered because of age, but less likely given no history of malignancy, normal inflammatory markers, MRI without suspicious marrow-replacing lesion, and DEXA showing osteoporosis supporting fragility fracture.
  • Vertebral osteomyelitis/discitis — less likely due to absence of fever, normal/near-normal inflammatory markers, and acute sudden onset after mechanical strain.
  • Acute mechanical lumbar strain or paraspinal muscle injury — possible but focal vertebral tenderness and imaging demonstrating compression fracture make this less likely.
  • Acute symptomatic lumbar spondylolisthesis or fracture from high-energy trauma — history lacks high-energy mechanism.

Management

• Acute pain control:
  • Immediate: provide multimodal analgesia — regular paracetamol, consider short course oral opioid (e.g., oxycodone) for severe pain while monitoring diabetes, avoid NSAIDs if renal function marginal or other contraindications; consider IV opioids in ED if pain uncontrolled.
  • Adjuvants: consider short-term muscle relaxant or low-dose opioid combination; neuropathic agents only if radicular neuropathic pain present.
• Mobility and supportive care:
  • Encourage mobilization as tolerated with assistive devices; consider fitting a thoracolumbar orthosis (brace) for comfort while erect.
  • Physiotherapy referral for safe mobilization, posture training, and home safety/fall assessment before discharge.
• Definitive/secondary prevention for osteoporosis:
  • Start calcium and vitamin D supplementation (e.g., calcium 1000–1200 mg/day and cholecalciferol to correct deficiency) immediately.
  • Resume/commence anti-resorptive therapy after assessment (e.g., oral bisphosphonate if tolerated and renal function adequate, or IV zoledronic acid if GI intolerance) — coordinate with primary care/endocrinology.
  • Arrange DEXA if not already available and fracture liaison service referral for secondary prevention.
• Specialist referral and procedures:
  • If pain remains severe and uncontrolled despite optimal analgesia, consider referral to orthopaedic/spinal team for consideration of vertebroplasty/kyphoplasty.
  • Urgent MRI and neurosurgical/orthopaedic review if new or progressive neurological deficit, signs of spinal cord compression, or suspicion of pathological fracture from malignancy.
• Address comorbidities and modifiable risks:
  • Optimize diabetes control with primary care/diabetes team (HbA1c 7.8%).
  • Review steroid exposure and inhaler use; minimize future systemic steroid courses if possible.
  • Arrange falls risk assessment at home and social support given she lives alone.
• Follow-up:
  • Short-term outpatient spine clinic or fracture clinic follow-up within 1–2 weeks; osteoporosis clinic/fracture liaison service within 4 weeks.

Key Learning Points

• Vertebral compression fractures can occur after minor trauma in older patients with osteoporosis and commonly present with acute, focal back pain and point tenderness; a clear history of a specific event is a helpful clue.

• Start with plain radiographs to identify compression fractures; MRI is the investigation of choice when there is concern for spinal cord compromise or to exclude underlying malignancy/infection.

• Management balances acute analgesia, early mobilization and supportive bracing, and secondary prevention of further fractures (vitamin D/calcium and anti-resorptive therapy); consider vertebroplasty/kyphoplasty for refractory severe pain after multidisciplinary assessment.