Lumbar Spine Vertebral Fracture in 6 yr old Ambulatory, Steroid Treated, DMD patient with Acute Back Pain After a Fall: Review of Screening Guidelines


Clinical Management

Poster Number: 14


Virginia Kaperick, MD, Medical College of Wisconsin, Children's Wisconsin

Our patient is a 6 year old with Duchenne Muscular Dystrophy (DMD), on chronic glucocorticoids, who presented to his routine MDA clinic appointment with acute severe low back pain diagnosed with new vertebral fracture. He was diagnosed with DMD at 4 years, 11 mo old and started on daily steroids a short time later. At age 6 years he enrolled in a research trial and received a course of high dose steroids ending several months prior to this visit. The evening before his appointment he fell on his bottom resulting in acute severe low back pain. Scheduled screening spine xrays were concerning for possible early vertebral fracture in L5. Scheduled bone density (DXA) scan on same day revealed a Total Body Less Head (TBLH) Z-score -2.0, however very low Lumbar Spine (LS) Z-score of -7.5, noting computer unable to automatically mark spine requiring manual placement by technologist (likely from acute soft tissue inflammation and edema). No prior x-ray or DXA imaging available. His pain remained moderate to severe over following 8 days, with slow improvement with supportive care over subsequent weeks. Follow up 8 weeks later noted intermittent mild low back pain with stairs. Repeat imaging was definitive for L5 vertebral fracture (25% height loss) and compression abnormalities in multiple other levels, with DXA LS z-score now -2.0. In accordance with current recommendations following vertebral fracture diagnosis, he was started on twice yearly IV zoledronic acid infusions.

Learning points to be included in poster:
1.Review of 2018 DMD Care Considerations Guideline recommendations of early spine imaging and DXA screening.
2.Early imaging in acute phase limits identification of bone injury, consider follow up imaging to confirm when clinically suspicious.
3.Current guidelines recommend early treatment with IV zoledronic acid for bone protection, and prevention of recurrent fractures and vertebral fracture cascade.