• Daniel B Marcus, Paul C Lee, and David E Fish.
• Santa Cruz Medical Foundation Department of Physical Medicine, Santa Cruz, California 95065, USA. marcusdb@sutterhealth.org
• Pain Med. 2008 Oct 1; 9 (7): 866-70.

ObjectiveTo report a case in which pain preceded computer axial tomography (CT) and scintigraphic findings in an osteoporotic vertebral compression fracture.Design/SettingReport of a patient presenting to a physical medicine/pain medicine outpatient clinic.PatientEighty-seven-year-old female with history of osteoporosis and previous vertebral compression fracture with new onset, atraumatic, axial thoracic pain.InterventionsThoracic spine CT, bone scintigraphy, kyphoplasty (Kyphon-Medtronic, Sunnyvale, CA).Outcome MeasuresNot applicable.CaseHistory and physical exam were suggestive of thoracic compression fracture. CT and bone scintigraphy were negative for vertebral compression fracture. A CT of the pulmonary arteries during an unrelated hospital admission less than two weeks after initial presentation revealed a compression fracture at T7. Pain report was unchanged except for an increase in intensity. Follow-up X-ray and CT revealed a compression fracture at T7 with loss of 80% of vertebral height. Pain was successfully treated with kyphoplasty.ResultsCT and bone scintigraphy performed early after pain onset did not reveal a vertebral compression fracture. Within 2 weeks, fracture was evident on further imaging. The pain resolved following an intervention directed at the fracture.ConclusionThe patient's pain preceded CT and scintigraphic evidence of the osteoporotic vertebral compression fracture. It is possible that pain is an early sign of impending osteoporotic compression fracture, or microtrabecular fracture, prior to anatomic and physiologic changes. Magnetic resonance imaging may be the imaging study of choice rather than bone scintigraphy in identification of noncollapsed osteoporotic compression fracture. Earlier identification and treatment of vertebral compression fractures may reduce kyphosis and associated sequelae.

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