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A 59-year-old female, presents at the clinic with severe, persistent middle-to-lower back pain. She
developed the pain suddenly 3 days ago, after relocating a heavy potted plant in her garden. Upon
physical examination by her GP, patient is thin, 161cm tall and weighs 55kg. Her blood pressure,
pulse rate and temperature are all in normal range. Upon questioning the patient reveals she had a
hysterectomy 9 years ago and discontinued hormonal replacement therapy (HRT) 5 years ago. She is
a non-smoker and on average she drinks <4 alcoholic drink/day. Apart from the use of a
corticosteroid inhaler for her asthma she doesn’t take any other medication or supplements. The
patient doesn’t have hirsutism or striae. She also states that her mother suffered a hip fracture at
the age of 78 after a fall in her home

59-year-old female
severe, persistent middle-to-lower back pain

3 day history after relocating a heavy potted plant

thin, 161cm tall and weighs 55kg

BP, PR, T, all normal

Hysterectomy 9 yrs ago, discontinued HRT 5 yrs ago

non-smoker, <4 alcoholic drink/day

use of corticosteroid inhaler for asthma, no hirsutism, no abdominal striae

parental history of a hip fracture at age 78

 Musculoskeletal

 Osteoporosis
 Cushing’s syndrome
 Malignant disease
 Osteogenesis imperfecta
 Osteomalacia
 Osteomyelitis
 Hyperparathyroidism
 Spinal disc herniation
 Vertebral fracture

 Osteoporosis due to her age, her severe and persistent back pain which may be due to a
fracture after relocating a heavy plant, having had a hysterectomy and discontinuing HRT.
Alcohol consumption, use of corticosteroid inhaler and her parental history of hip fracture
are all risk factors for this disorder.

is another differential because of her age and back pain which could be due to a tumour which lead to a pathological fracture. The results in red indicate the absence of anaemia and therefore the absence of chronic bleeding. In osteomyelitis we would expect the patient to present with high temperature and other signs of infection.  In Cushing’s syndrome we would expect to see trunk obesity. . hirsutism and abdominal striae. The results in blue indicate the absence of infection and inflammation: neutrophils and ESR are within normal ranges.  A spinal disk herniation should also be considered and needs to be investigated as the patient may simply have a herniated disc following the relocation of the heavy plant. which may have occurred due to a pathological fracture in the presence of demineralized bone.  The patient may have sustained a vertebral fracture due to the presence of an underlying disease that may be associated to aging or simply due to heavy lifting. High parathyroid hormones leads to an increase bone resorption and hypercalcaemia and this can also lead to pathological fracture and back pain. INVESTIGATIONS Laboratory medicine  Blood test o Haematology o Biochemistry  Urine sample o Biochemistry Medical radiations Haematology Blood Test Results Haematology results show normal values for all parameters. either primary such as multiple myeloma or secondary.  Malignant disease.  Hyperparathyroidism is another differential as post-menopausal women have an increase risk or the primary disease.  Osteomalacia should also be considered due to her back pain. The results in green indicate the absence of malignancies: metamyelocytes and myelocytes are not present. Osteogenesis imperfecta is a congenital disease.

The normal blood profile suggests the absence of infection. while the absence of paraprotein in the blood also excludes multiple myeloma. is marginally elevated as expected in osteoporosis. Bone specific alkaline phosphatase (BALP) – a marker of bone metabolism. indicative of the patient’s hysterectomy. . The urinary cross-linked telopeptide of type 1 collagen (uNTX) are slightly elevated – a specific marker of human bone resorption (loss of bone). Low elevation of uNTS is a typical indicator of osteoporosis. while extremely high levels of 1. discontinued HRT and post-menopausal stage in life. inflammatory disorder or malignant disease Blood and Urine Biochemistry Results  The biochemistry urinary results show slightly elevated calcium levels which may indicate that bone is not absorbing calcium from the diet.  The oestrogen levels are lower than normal.5-2 are found in patients with osteomalacia and bone tumours. Levels > 1g/24h urine collection is consistent with diagnosis of multiple myeloma. This is consistent with the VitD deficiency or low VitD levels in the blood. while the normal parathyroid hormone levels also exclude hyperparathyroidism. Levels of BALP are highly elevated 3-4x and higher in osteopmalacia or osteosarcoma. If urine calcium levels exceed 300mg/24h of urine collection this would indicate osteomalacia. The calcium levels in the blood are also normal and consistent with osteoporosis and not with hyperparathyroidism and osteomalacia where the levels may be increased.  The results in blue are all normal such as the monoclonal Jones-Bence protein levels in urine.

such as: dual energy X-ray absorptiometry (DXIA). The first one at the neck of femur.  DXIA is a means of measuring bone density. In our patient’s case. . plain film imaging of the thoracic spine was undertaken. It is the number of standard deviations of the bone mineral density measurement above and below that of young healthy adults of the same sex. In this case with the fracture being present and the patient presenting with risk factors of osteoporosis.Overall. Two X-ray beams with different energy levels are aimed at the patient’s bones.  The T score compares the patient’s bone density to the peak bone density of young adults. Medical Imaging  A patient that presents with tenderness and midline spinal pain requires plain film radiographic imaging to rule an organic or traumatic cause of spinal pain.  The Z score compares the patient’s bone density to that of adults of the same age. these results are consistent with osteoporosis. There is mild associated kyphosis but no malalignment of the spine. It is the number of standard deviation of the bone mineral density measurement above and below of that of adults of same age and sex. The plain film imaging of frontal and lateral projections of the thoracic spine demonstrate an anterior wedge compression fracture of the T7 vertebrae with a height loss of approximately of 30%. additional studies were undertaken. the second one at the lumber spine. When soft tissue absorption is subtracted out we can calculate the bone mineral density.

lifestyle factors: > 2 alcoholic drinks/day and smoking. leading to higher risk of fracture than normal bone  The underlying mechanism is an imbalance between bone resorption and bone formation. In our patient’s case the T score spine was – 2. A patient with normal bone density will have a T score of 1. T score hip – 1. while the blood tests detected slightly elevated BALP and low oestrogen and VitD levels.8 and Z score – 2. height loss > 3cm. low levels of physical activity. The parathyroid hormone stimulates bone resorption by osteoclastic activity and this regulates blood calcium levels. requires normal secretion of oestrogen and parathyroid hormones. In our case the patient has presented with a fracture of T7. . fractures can occur even with a minor bump or fall  Risk factors: family history. It also acts on the kidney to activate VitD. thin build.  Normal calcium metabolism in a young woman. in her reproductive years. medication that decrease bone strength (corticosteroids for longer than 3 months).3 which indicate that the patient has mild osteoporosis SUMMARY OF RESULTS  The haematology results were normal. and this along with a diet that meats the daily Ca requirements allows Ca to be absorbed from the small intestine and this also maintains normal blood Ca levels.  Calculation of the Z score is undertaken if the patient presents with a fracture. FINAL DIAGNOSIS  Osteoporosis  Vertebral fracture Osteoporosis  Common disease that causes the bones to become brittle. All results being consistent with osteoporosis. no infection. maintain a balance between bone resorption and bone formation. A Z score of negative 2 or below triggers investigations of underlying disease. either in tablet form or via a high dose puffer.6.0 or above. excluding other causes of bone mineral loss.5 which are both indicative of osteoporosis. oestrogen deprivation in men with prostate cancer can affect bone density. inflammation or malignant disease. causing bones to lose minerals more quickly than the body can replace them  Reduced bone density or mass. while DXIA revealed a Z score below zero and T score of the spine below – 2.  The plain film X-ray of a compression fracture of the T7 vertebral body and also mild kyphosis.  Biochemistry results detected slightly high urinary calcium and uNTX.

leads to overall decrease bone density or mass  Low oestrogen in women and low testosterone in men. hyperparathyroidism can predispose to osteoporosis  Plain film X-rays will show cortical thinning. as well as low VitD level. while DXA is considered the gold standard for osteoporosis as it measures bone mineral density TREATMENT All prevent further bone loss and prevent osteoporotic fractures  Bisphosphanates  Denosumab . increased radiolucency as well as kyphosis and any associated fractures. In this case there is an imbalance between bone resorption and bone formation. This along with a Ca deficient diet and a deficiency of VitD. Increased parathyroid hormone also decreases kidney activation of VitD which leads to decreased Ca absorption from the small intestine. leads to elevated levels of parathyroid hormone and excessive bone resorption in order to maintain normal blood Ca levels.  Ca metabolism in a post-menopausal woman with low oestrogen levels.

presented with severe. maintaining a healthy. vertebral fracture. both at the site of local pain and pain referral sites  Subsequent imaging should be requested to check progress Chiropractic  Manage patient by using low force or non-force techniques  Spinal manipulation via force adjustment is not appropriate in osteoporotic woman with a T7 vertebral fracture  Soft tissue technique on trigger points may assist to reduce pain  Muscle strengthening exercises can be done at home or in a local swinmming pool  General advice would be for general exercise. persistent pain in middle-to-lower back after lifting a heavy potted plant  Due to her age and risk factors for bone disease the differential diagnosis was: osteoporosis. increase dietary calcium. balanced diet and going out into the sunlight for 20min each day to promote VitD synthesis into the skin Osteopathy  Muscle energy techniques to improve body strength and posture with a focus on maintaining an increase in stability  Spinal manipulation – high velocity and low amplitude is not appropriate for an osteoporotic  Soft tissue treatment and articulation is appropriate in this case  Advice to undertake swimming as this reduces weightbearing whilst maintaining exercise SUMMARY OF CASE STUDY  The 59 yrs old female patient. malignant disease. osteomalacia. take VitD supplement and exercise regularly to support her bone health Complementary Medicine treatment Chinese medicine  Dietary advise: soups that contain bones in their preparation. all of which may present with a back pain. hyperparathyroidism.  Strontium ranelate Recovery from an osteoporotic fracture may include swimming exercises and hydrotherapy which have been shown to reduce further vertebral fractures PATIENT PROGNOSIS AND MANAGEMENT Conventional treatment  Good prognosis as osteoporosis in this patient is mild and it was detected early  The bone density can be stabilized and improved with monthly tablets of bisphosphonates (alendronic acid) which can also reduce the risk of fractures  The patient was also advised to reduce alcohol intake. malignant disease. spinal disc herniation. hyperparathyroidism and spinal disk herniation were all excluded . osteomalacia. increased consumption of diary products  Pain management: acupuncture. especially if a pathological fracture was sustained  Following laboratory testing and imaging investigation.

Which of the following is a significant factor in the development of osteoporosis in this patient? Select all correct answers a.0 and a T score of the spine below – 2.2. Her use of a corticosteroid inhaler d. a class of drugs used to increase bone density and reduce osteoporosis. Continue her usual alcohol intake c. treatment would complement and support the conventional treatment. What form of CAM treatment or advice would be regarded as inappropriate in this case? a. Acupuncture . Which test results aided the diagnosis of osteoporosis? Select all correct options a. Decrease her dietary calcium d. Spinal manipulation d. The absence of hirsutism and abdominal striae 2. Dual-energy X-ray absorptiometry (DXA) REVEALING A z SCORE BELOW . Diet with sufficient diary products c. overall complementary medicine treatment will support bone health QA 1.5 3. What advice was given to this patient with regards to treatment and management? a. soft tissue treatments and also provide advice with regards to appropriate exercise to reduce weightbearing. Take a monthly VitD supplement 5. Take a monthly tablet of alendronic acid b. Her post-menopausal stage in life b. Biochemistry results showing slightly high urinary calcium b. Haematology showing presence of infection and malignancy c. which can be administered daily. Which medical imaging test revealed the presence of a vertebral fracture? a. Magnetic resonance imaging (MRI) d. Her prior hysterectomy and discontinued hormone replacement therapy c. Chinese medicine would involve acupuncture and dietary advice. Computed tomography (CT) b. Plain X-ray c. while osteopathic would employ muscle energy techniques. Swimming exercises b. but for our patient who has mild osteoporosis she was recommended a monthly tablet or alendronic acid  She was also advised to alter her diet and lifestyle in order to increase VitD and calcium levels and to support her overall health  If the patient was to visit a CAM practitioner. Biochemistry showing low oestrogen levels d. weekly or monthly. PET scan 4. chiropractic would concentrate on low or non-force techniques and also provide lifestyle advice.  Final diagnosis was then determined: a compression fracture in T7 due to mild osteoporosis  The patient was treated with bisphosphonates.