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Spine J. 2013 Sep;13(9):1126-33. doi: 10.1016/j.spinee.2013.07.427.

Assessment of patient's pain-related behavior at physical examination may allow diagnosis of recent osteoporotic vertebral fracture.

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IUSM (Italian University of Sport and Movement), Rome, Italy. Department of Anatomy, Piazza Lauro De Bosis, 6 - 00135, Rome, Italy; Section of Orthopedic Surgery, Israelitic Hospital, Piazza San Bartolomeo all'Isola 21 Rome 00186 Italy. Electronic address:



Although innumerable studies have analyzed the multiple aspects of osteoporotic vertebral fractures, no study has focused on the clinical features related to spine pain in patients with recent osteoporotic vertebral compression fractures (VCFs).


To determine whether the assessment of pain-related behavior (P-RB) of patients with osteoporotic VCFs of recent onset may allow the fracture to be strongly suspected, or even diagnosed, at physical examination.


Pain-related behavior of elderly patients attending an outpatient spine clinic was evaluated on the basis of six consecutive movements made on the examining table.


Fifty-six patients complaining only of lumbar or thoracic pain. The fractured patients (FPs), representing the fracture group (FG), were the 19 who had a recent VCF, whereas the control group (CG) consisted of the remaining 37 patients.


Assessment of P-RB was based on six parameters: grimacing, sighing, clenching or blocking eyelids, gaping or strongly tightening the lips, need for help to take positions, and extreme difficulty to turn in the prone position. A score of 1 or a decimal was assigned to each parameter, the final score to each patient being 0 to 6. Three types of injury, acute (I), subacute (II), or chronic (III), were identified on the basis of the time elapsed from the probable occurrence of the fracture. The diagnosis of recent fracture was based on magnetic resonance images. Patients were videotaped during their movements. An examiner, unaware of the clinical history and diagnosis, gave a P-RB score to all patients and indicated whether they had to be placed in FG or CG, and also their presumable type of fracture. Subsequently, a DVD with the videotapes of all patients was given to three independent examiners, not specifically expert of spine conditions, who were asked to make the same evaluations as the first examiner.


The mean scores for P-RB given by the first examiner were 4.6 to FG and 0.7 to CG (p<.01). He identified as FPs 89% of those who were in FG. The type of fracture was indicated correctly in 88% of patients identified as FPs. The mean scores for the three types of fracture ranged from 5.4 (Type I) to 3.3 (Type III) (p<.001). The mean scores for P-RB given by the independent examiners to FG and CG were similar to those of the first examiner. The rates of correctness in identifying the type of fracture in patients indicated as FPs varied from 87% to 80%. The mean scores assigned to the patients included in the three types of fracture ranged from 5.4 to 2.8.


Pain-related behavior evaluation of patients with osteoporotic VCF during their movements on the examining table may allow to suspect, or even diagnose, the presence of a fracture, particularly in the initial 4 to 6 weeks after the occurrence. Even orthopedic surgeons not particularly familiar with spine care may be able to suspect the injury during physical examination.


Clinical diagnosis; Osteoporosis; Pain-related behavior; Recent fracture; Vertebral fracture

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