Msk Dermatology · Year 2 · from Msk Dermatology
Case 1: Postmenopausal Osteoporosis with Vertebral Compression Fracture
Patient Presentation
Demographics: 68-year-old Caucasian woman
Chief Complaint: "I've had back pain for two weeks that started when I was lifting groceries."
History of Present Illness: The patient reports acute onset of mid-back pain that began while lifting grocery bags from her car. She describes the pain as sharp and constant, rated 7/10 in severity. The pain worsens with movement and improves with rest. She denies any numbness, weakness, or bowel/bladder dysfunction. She notes she has "shrunk" about 2 inches over the past decade.
Past Medical History:
- Menopause at age 50
- Hypothyroidism
- No prior fractures
Medications:
- Levothyroxine 75 mcg daily
Social History:
- Never smoker
- Occasional wine with dinner
- Sedentary lifestyle
Family History:
- Mother had hip fracture at age 72
Physical Examination
- Vital Signs: BP 132/78 mmHg, HR 76 bpm, BMI 22 kg/m2
- Spine: Point tenderness at T12, no palpable step-off, mild kyphosis
- Neurological: Intact strength and sensation in lower extremities, normal reflexes
Workup and Results
Laboratory Studies:
| Test | Result | Reference Range |
|---|---|---|
| Calcium | 9.4 mg/dL | 8.5-10.5 mg/dL |
| 25-OH Vitamin D | 18 ng/mL | 30-100 ng/mL |
| TSH | 2.1 mIU/L | 0.4-4.0 mIU/L |
| Creatinine | 0.9 mg/dL | 0.6-1.2 mg/dL |
| Alkaline Phosphatase | 85 U/L | 44-147 U/L |
Imaging:
- Thoracolumbar X-ray: T12 vertebral compression fracture with approximately 30% height loss, no retropulsion
- DXA Scan:
- Lumbar spine T-score: -2.8
- Femoral neck T-score: -2.4
- Total hip T-score: -2.2
Clinical Image
Lateral thoracolumbar radiograph demonstrating vertebral compression fracture with anterior wedging, typical of osteoporotic fracture. Source: Wikimedia Commons, Public Domain.
Diagnosis
Primary Osteoporosis with T12 Vertebral Compression Fracture
Diagnostic Criteria Met:
- DXA T-score of -2.8 (less than -2.5) at lumbar spine
- Low-trauma fragility fracture
- Vitamin D insufficiency contributing to bone loss
Treatment Plan
Acute Management:
- Pain control with acetaminophen and short-term opioids as needed
- Activity modification with gradual return to mobility
- Thoracolumbar orthosis (TLSO) brace for comfort
Osteoporosis Treatment:
- Calcium: 1200 mg daily (dietary plus supplement)
- Vitamin D3: 2000 IU daily to achieve serum 25-OH vitamin D >30 ng/mL
- Bisphosphonate: Alendronate 70 mg weekly
- Counseled on proper administration (empty stomach, remain upright 30 minutes)
- Weight-bearing exercise: Walking program as pain allows
- Fall prevention: Home safety assessment
Follow-up:
- Repeat DXA in 2 years
- Monitor vitamin D levels in 3 months
- Reassess fracture risk and treatment response annually
Teaching Points
- T-score interpretation: A T-score of -2.5 or below defines osteoporosis; this patient's T-score of -2.8 with a fragility fracture indicates severe osteoporosis
- Vitamin D deficiency: Common in osteoporosis and must be corrected for optimal response to bisphosphonates
- RANK/RANKL pathway: Bisphosphonates induce osteoclast apoptosis; denosumab (RANKL inhibitor) is an alternative for patients who cannot tolerate bisphosphonates
- Fragility fracture: Defined as a fracture from low-energy trauma (e.g., fall from standing height or less), indicating compromised bone strength