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VCF – Differential Diagnosis

Presentation

Medical history. Patients with osteoporotic VCF most often present with acute onset of back pain attributed to an everyday activity such as lifting a bag of groceries. Pain is typically central or axial but can occasionally radiate, especially if the nerve roots are involved. More severe neurologic involvement only occurs when the vertebral body has completely collapsed. Pain is often exacerbated by standing or walking. Pain as long as one year is not unusual. [48-50]

Not all VCFs present with typical complaints. Unusual findings include shortness of breath (due to loss of chest wall function from the VCF), protruding abdomen (due to loss of lumbar lordosis), or depression. Also, pain may not always be remarkable. In fact, it is thought that only 1/3 of all VCFs present with acute pain. [72] Since back pain is common in the elderly due to other reasons, any patient with acute onset of back pain should be evaluated for VCF. [10,20-22,51,52]

Physical examination. Physical examination can show tenderness to palpation of spinous processes, thoracic kyphosis or loss of lumbar lordosis (especially if multiple fractures are present), dowager’s hump and/or loss of total body height. On occasion patients are tachypneic due to loss of pulmonary function.

Differential Diagnosis

The differential diagnosis of acute or chronic back pain in the elderly is large. Probably the most common alternative cause is degenerative disc disease.

Figure 1. Differential diagnosis of acute and chronic back pain in the elderly.

Vertebral body compression fracture due to osteoporosis
Cancer-related fracture (e.g., myeloma)
Traumatic fracture
Scheuermann’s disease
Congenital abnormalities, scoliosis
Spondylosis
Tuberculous spondylitis
Schmorl's nodes
Degenerative disc disease
Lumbar fact arthropathy
Lumbar spondylolysis and spondylolisthesis

Diagnostic Workup

The diagnostic workup of patients with suspected VCF begins with a lateral spine film. The film should cover T5 to L5, the areas in the spine with the highest risk of VCF. In the absence of a prior film, the lateral spine film does not differentiate acute from chronic fracture. However, a repeat lateral spine film can often show acute vertebral body height loss, which is diagnostic of acute fracture. A magnetic resonance imaging (MRI) scan with STIR or T2 sequences can distinguish whether a VCF is acute. When acute, the STIR sequences shows hyperintensity, reflecting edema inside the vertebral body. Edema indicates that the fracture has not yet completely healed. If the MRI shows fracture but the STIR sequence is negative, the VCF is considered chronic and healed. In this case, alternative diagnoses should be pursued. CT scan is occasionally performed (especially if the fracture is related to high-energy trauma) to better define bony anatomy.

 MRI is the most commonly used test to diagnose acute VCF

Lateral Spine Films Underdiagnosed

Multiple studies have indicated that physicians commonly underdiagnose VCF on lateral spine films. [5] Underdiagnosis is unfortunate, since early treatment of VCF is key to improving clinical outcomes.


TOPICS IN THIS SECTION:
Vertebral Compression Fractures (VCFs)
Differential Diagnosis
Acute consequences
Chronic consequences

 
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