Radiology Review

Does Chronic Complaining Mask Acute Problem?

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Does Chronic Complaining Mask Acute Problem image

An 80-year-old woman who resides in a nursing home is sent to urgent care for evaluation of back pain. There have been no witnessed injuries or falls. The notes from the nursing home staff indicate that the patient, who has severe dementia, tends to chronically complain about one ailment or another. However, the patient’s family seems to feel she is complaining more than usual.

Her only other medical history is controlled hypertension. Her vital signs are stable. On physical exam, you note an elderly female who is pleasant but very confused. She is able to follow simple commands and appears to be able to move all her extremities well, with no obvious neurologic compromise. Inspection of her back does not demonstrate any obvious wounds, bruising, or step-offs. She does have generalized tenderness as you palpate her lumbar region.

The triage nurse already ordered lumbar spine radiographs, which have been completed. The lateral view is shown. What is your impression?


Does Chronic Complaining Mask Acute Problem image


The radiograph demonstrates age-related degenerative changes. Of note is a moderate compression fracture of L3 with close to 50% loss of height. It is difficult to say for sure the fracture is acute; by plain film alone, it would be deemed age indeterminate.

Of concern, though, is the posterior portion of the superior endplate of L3, which appears to be posteriorly displaced into the spinal canal. This finding suggests possible retropulsion and, if this fracture was in fact acute, would suggest a possible unstable fracture. Further imaging is warranted.

The patient underwent noncontrast CT of the lumbar spine, which demonstrated that the fracture was acute. It also indicated that there was dorsal retropulsion causing close to 50% canal compromise. The patient was subsequently admitted for further workup and evaluation.

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