A 67-year-old woman presents to accident and emergency with acute severe back pain in the thoracic region. She does not recall any recent trauma or falls. She denies any chest pain, palpitations, or new respiratory symptoms.

She has chronic asthma on regular budesonide and salbutamol, is a heavy smoker, and has BMI 17.

Her heart rate is 105 but her observation are otherwise unremarkable. On examination her chest is clear, good air entry bilaterally, with resonant percussion. Abdomen is soft, non-tender. She is not overly tender on palpation on any spinous processes. She has limited range of movement, due to pain, on lateral rotation and forward flexion of her spine. Full neurology exam is unremarkable.

Electrocardiogram shows sinus tachycardia.

Which of the following is the most likely diagnosis?

Options:
explanation: Pancreatitis presents with acute central/epigastric abdominal pain, often radiating to the back. They will almost certainly have a tender abdomen, often with peritonism, and will rarely complain of back pain alone. Aside from long-term use of corticosteroids, this patient has no other risk factors for acute pancreatitis. There is no indication in the question that she is suffering from nausea, vomiting, or loose stools. This patient has numerous risk factors for osteoporosis and has pain on lateral rotation and forward flexion of her spine - this should raise concerns of an osteoporotic vertebral fracture
name: Acute pancreatitis
label: e
answer: no
explanation: The patient does have sinus tachycardia and acute pain in her thorax, which would raise concern of a pulmonary embolism. She denies anterior chest pain or any new respiratory symptoms, however, and her pain is described as "severe back pain". This makes pulmonary embolism less likely. This patient has numerous risk factors for osteoporosis and has pain on lateral rotation and forward flexion of her spine - this should raise concerns of an osteoporotic vertebral fracture
name: Pulmonary embolism
label: c
answer: no
explanation: This patient has presented with acute severe thoracic back pain. This should not be readily dismissed and is often a sign of acute pathology. She has a number of risk factors for osteoporosis: post-menopausal, female gender, low BMI, current smoker, and longstanding corticosteroid use. Patients with osteoporotic vertebral fractures often have mild or no history of trauma and they may present with acute worsening back pain with no trigger. Her tachycardia is likely primarily a result of her pain, but could also be compounded from likely small vessel disease from smoking. She has pain on lateral rotation and forward flexion of her spine, providing further evidence of possible vertebral fracture. Though she lacks severe tenderness on palpation of her spinous processes, this does not absolutely rule out vertebral fracture, particularly if the pathology is more anteriorly located
name: Osteoporotic thoracic vertebral fracture
label: a
answer: yes
explanation: Patients with asthma are at higher risk of spontaneous pneumothorax although more commonly when they are receiving positive pressure ventilation as they require high pressures to open a narrow airway resulting in barotrauma and alveolar rupture. A patient with pneumothorax would typically present with acute shortness of breath and chest pain. There would likely be signs on examination such as absent air entry from the affected area and hyper-resonant percussion (although these can be easily missed in practice if the pneumothorax is small). This patient has numerous risk factors for osteoporosis and has pain on lateral rotation and forward flexion of her spine - this should raise concerns of an osteoporotic vertebral fracture and is a more likely diagnosis
name: Simple pneumothorax
label: b
answer: no
explanation: Aortic dissection can often mimic other conditions - presenting typically as acute severe, often "tearing", back/chest pain, sweating, collapse, or lightheadedness. You must have a high index of suspicion as it can be easily missed, carrying a 50% (type A dissection) and 10% (type B dissection) mortality if not treated. While it should be in your differentials, as she has acute back (not chest) pain, a normal ECG, with pain on movement of the thoracic spine - aortic dissection is less likely than a thoracic vertebral fracture
name: Aortic dissection
label: d
answer: no

Correct answer: a