Spinal-origin abdominal pain secondary to silent osteoporotic compression fractures: A case report

Abstract

Abdominal pain in older individuals is frequently attributed to visceral disorders; however, vertebral compression fractures can present with isolated abdominal pain. Herein, we report a diagnostically challenging case that has not been previously published as a preprint. A woman in her early 80s presented with a 2-week history of persistent right upper quadrant dull pain, which had not been relieved by antispasmodic medications. Physical examination revealed mild tenderness in the right upper quadrant. Laboratory tests showed mild anemia (hemoglobin, 91 g/L) and severe osteoporosis. Results of contrast-enhanced computed tomography and endoscopy did not explain the cause of the pain. After failure of conservative treatment, magnetic resonance imaging revealed a new compression fracture of the T8 vertebra (considered as the source of pain corresponding to the right upper quadrant dermatome) and an incidentally discovered new fracture at L4. Percutaneous vertebroplasty was performed on the T8 and L4 vertebrae, and the pain was completely relieved within 24 h postoperatively. For older patients with unexplained abdominal pain, the possibility of asymptomatic osteoporotic compression fractures should be considered. Early spinal magnetic resonance imaging can help avoid diagnostic delay.

Background

Isolated abdominal pain may originate from thoracolumbar compression fractures via dermatomal referral. ¹ Because elderly patients often lack a clear traumatic history, such fractures are easily overlooked. Herein, we describe a diagnostically challenging case that highlights the importance of systematic evaluation.

Case presentation

This report was prepared in accordance with the Case Report (CARE) guidelines. ² A previously independent woman in her early 80s was admitted with a 2-week history of right upper quadrant (RUQ) dull pain, which was exacerbated by movement and coughing and showed a poor response to analgesic medications. She was admitted to Hebei Provincial People’s Hospital, Shijiazhuang, China, in mid-2024. She had no fever, vomiting, or jaundice. Her past history included hypertension, type 2 diabetes, chronic hepatitis B, and cholecystectomy (Table 1).

Table 1

Summary of the case

1	Patient (sex and age)	A woman in her early 80s
2	Final diagnosis	Acute compression fracture of T8 with marrow edema; incidental L4 fracture
3	Symptoms	2-week history of right upper-quadrant dull pain exacerbated by movement and coughing
4	Clinical procedure	Day	Key event
		1–2 and 6	Contrast-enhanced CT/US/endoscopy enhanced CT: no intra-abdominal cause
		Therapy	Enemas, vasodilator therapy, osteoporosis treatment, and antianxiety treatment; pain persisted (NRS: 7–8/10)
		16	MRI revealed acute compression fractures of T8 and L4
		17	Early vertebroplasty indicated due to (a) MRI evidence of acute edema, (b) severe disabling pain despite analgesics, and (c) high risk of further collapse (T-score, −3.8)
		21	Percutaneous vertebroplasty under local anesthesia; pain resolved (NRS: 0–1/10)
		26	Discharged home
		54	Outpatient day 28 follow-up: pain-free, no complications
5	Specialty	Silent osteoporotic compression fractures should be considered in older patients with unexplained abdominal pain. Early spinal MRI can prevent diagnostic delay

CT: computed tomography; MRI: magnetic resonance imaging; NRS: numeric rating scale; US: ultrasound.

On examination, she adopted a flexed posture. There was mild tenderness on palpation of the RUQ, with no percussion pain over the thoracic and lumbar vertebrae. Basic blood tests revealed normocytic anemia (Hemoglobin (Hb), 91 g/L) and severe osteoporosis (T-score, −3.8). ³ Contrast-enhanced computed tomography (CT) revealed postcholecystectomy status and fractures at T6–T8 and T12–L1, with a 38% loss of height in the fractured vertebral body and no obvious kyphotic deformity of the T8 vertebra. Gastroscopy revealed mild bile-reflux gastritis, whereas colonoscopy was normal. Despite 2 weeks of enemas, vasodilator therapy, osteoporosis treatment, and antianxiety treatment (intravenous injection of 30 mg papaverine hydrochloride every 8 h; intravenous infusion of 15 mg ketorolac tromethamine; enema with 110 mL glycerin; oral administration of 0.25 μg calcitriol soft capsules once daily; and intravenous infusion of 2 mg ibandronate sodium), the pain score remained greater than 7 points. Reexamination revealed that Carnett’s test was positive, suggesting abdominal wall pain rather than intra-abdominal pathology, consistent with a spinal origin. Therefore, the thoracolumbar spine magnetic resonance imaging (MRI) was performed using sagittal T1-weighted, T2-weighted, and short tau inversion recovery (STIR) sequences (slice thickness, 4 mm; field of view (FOV), 320 mm). Although T8 and L4 exhibited acute fracture edema on MRI (acute fracture was defined by hyperintense marrow edema on STIR), T8 was identified as the primary pain generator for following reasons: (1) Dermatomal correlation. The patient’s RUQ pain corresponded to the T8 dermatome (xiphoid/subcostal region). ⁴ In contrast, L4 innervates the lower limb and could not explain the abdominal symptoms. ⁵ (2) Focal tenderness. Maximal tenderness was noted over the T8 spinous process and right costovertebral angle (Figure 1), whereas L4 tenderness was less pronounced. (3) Symptom reproduction. Pain was worsened by thoracic extension and coughing. Based on risk factors for unstable fracture indicated by thoracolumbar MRI, including acute fracture signs (fractures with edema), mechanical pain patterns, severe osteoporosis, and persistent pain after 2 weeks of bed rest, as well as after informing the patient of the risks associated with conservative treatment, including infection, pressure ulcers, and thrombosis formation, surgical treatment was recommended. The patient and her family signed written informed consent for percutaneous vertebroplasty. Finally, percutaneous pedicle vertebroplasty was performed on T8 and L4 via a transpedicular approach using polymethylmethacrylate (PMMA) bone cement (injection volume: T8, 2mL; L4, 7mL). Injection was stopped upon observing adequate vertebral filling or any epidural or cortical leakage.^6,7 Pain scores (numeric rating scale (NRS)) ⁸ were as follows: baseline, 8/10; 24 h postprocedure, 1/10; discharge (day 2), 0/10; and day 28 follow-up, 0/10. Postoperative X-ray (Figure 1) confirmed cement augmentation of the T8 and L4 vertebral bodies, with partial restoration of vertebral body height. After surgery, the patient was instructed to wear a thoracolumbar orthosis for 8 weeks. She was prescribed 2 mg intravenous ibandronate sodium every 6 months, with calcium and vitamin D supplementation to prevent recurrence of osteoporosis. The patient was discharged on postoperative day 2. There were no complications (including cement leakage, infection, or neurologic injury), readmissions, or adjacent-level fractures. All clinical images (Figure 1) are original, unpublished materials from our institution. Written informed consent for publication of images was obtained from the patient. No copyrighted material from external sources was used. All patient identifier information has been removed; age is reported as range, and dates are presented only as the day of the month to protect privacy. This case report was prepared in accordance with the CARE guidelines (2013). During manuscript preparation, Ki-mi was used for language editing, translation assistance, and structural organization of the text. All medical content, data interpretation, clinical decisions, and scientific conclusions were independently generated and validated by the authors. No artificial intelligence (AI) tools were used for image processing or literature search.

Figure 1.

(a) Preoperative sagittal STIR MRI showing an acute T8 compression fracture with hyperintense marrow edema, presumed to be the pain generator corresponding to the right upper quadrant dermatome. Slice thickness, 4 mm; FOV, 320 mm; scale bar = 1 cm. (b) Preoperative sagittal STIR MRI showing an incidental L4 fracture. Slice thickness, 4 mm; FOV, 320 mm; scale bar = 1 cm. (c) Preoperative CT image showing a 38% loss of height in the fractured vertebral body and no obvious kyphotic deformity of the T8 vertebra. Scale = 2.5 cm. (d) Postoperative X-ray confirming cement augmentation of the T8 vertebral body with partial restoration of vertebral body height. Scale = 1 cm. (e) Postoperative X-ray confirming cement augmentation of the L4 vertebral body with partial restoration of vertebral body height. Scale = 1 cm. CT: computed tomography; MRI: magnetic resonance imaging; STIR: short tau inversion recovery; FOV: field of view.

Discussion

Previous studies have shown that, even with the widespread use of CT and ultrasonography, a definitive cause remains elusive in more than one-third of cases, underscoring the need for a more efficient abdominal pain evaluation pathway to reduce the proportion of cases labeled as “nonspecific abdominal pain.” In the present case, spinal-origin abdominal pain was ultimately confirmed only after stepwise exclusion of intra-abdominal disorders based on clinical findings and ancillary investigations, highlighting the diagnostic complexity of this condition. Compression fractures can generate abdominal pain through somatovisceral convergence at the T8–L2 levels. The T8–T12 somatovisceral convergence mechanism involves dorsal root ganglia at these levels receiving convergent input from intercostal (somatic) and splanchnic (sympathetic) nerves. Fracture-induced peripheral sensitization results in misreferral of pain to the abdomen, analogous to cardiac T1–T4 referral. ¹ Lin et al. ⁹ divided 37 patients with osteoporotic fractures into a conservative treatment group and a percutaneous vertebroplasty group. Among them, 25 cases presented with symptoms of abdominal distension or constipation, and only 2 cases had abdominal symptoms related to eating or defecation. They found that the improvement in pain scores in the surgical group was significantly different from that in the conservative group. Our case is unique, characterized by the absence of back pain and bilateral fractures (T8/L4), in which dermatomal mapping accurately identified the symptomatic vertebra, enriching the spectrum of clinical manifestations. When multiple compression fractures occur simultaneously, identifying the pain source requires dermatomal mapping combined with clinical correlation. In this case, the T8 fracture explained the entire symptom complex. From the nociceptive pathway perspective, the T8 spinal nerve receives convergent input from the lower thoracic wall and parietal peritoneum, predisposing it to referred visceral pain. In contrast, L4 fracture was excluded. L4 innervates the leg via the femoral nerve and does not contribute to abdominal sensation; therefore, its fracture was considered clinically silent. ⁵ A recent study identified a previously unrecognized peripheral neuronal substrate underlying visceral pain sensitization and the concomitant emergence of referred somatic hypersensitivity. ¹⁰ These findings highlight that not all radiologic fractures cause symptoms, and targeted therapy depends on accurate clinical localization. Our patient illustrates three pitfalls: (a) absence of overt back pain; (b) misleading RUQ tenderness; and (c) multiple comorbidities diverting attention from the spine. Vertebroplasty can rapidly relieve pain and prevent further collapse in cases where MRI confirms acute bone edema and analgesia remains ineffective for more than 1–2 weeks. It has been shown to provide faster analgesia than conservative therapy. ¹¹ Although the clinical manifestations of the L4 fracture were not obvious, percutaneous vertebroplasty of the L4 segment was still performed based on the following evidence-based indications: (a) severe osteoporosis (T-score, −3.8), which belongs to a high-risk category for delayed fracture progression; (b) presence of unstable radiologic signs, as the MRI STIR sequence showed high signal intensity consistent with an acute fracture with active edema; and (c) multilevel fracture pattern (T8 + L4). For patients with severe osteoporosis and multilevel acute fractures, prophylactic surgery may be considered to prevent future symptomatic conversion and avoid secondary surgery. This approach aligns with the principle of “individualized comprehensive management” for high-risk older patients outlined in the “Chinese Guidelines for the Diagnosis and Treatment of Osteoporosis in the Elderly (2023).” ¹² In this case, the absence of complications and complete relief of pain (NRS, 8→0) supports the safety and efficacy of the surgery. Limitations include the absence of a formal diagnostic nerve block to confirm T8 as the sole pain source; the single-case design limits generalizability; and the short follow-up period (4 weeks) does not allow assessment of long-term recurrence or adjacent-level fracture risk. However, the combination of MRI edema, dermatomal correlation, and immediate postprocedure pain relief provided strong circumstantial evidence. The early decision to perform vertebroplasty, guided by acute imaging findings and unsuccessful conservative pain management, prevented prolonged suffering and unnecessary investigations.

Conclusion

Silent osteoporotic compression fractures should be included in the differential diagnosis of unexplained abdominal pain in older patients. A focused spinal examination and low-threshold MRI can facilitate prompt and effective treatment.