After a Fall, What Cause of Back Pain?

Figure. X-ray image from ED; AP view.

A 38-year-old man slips at home while rushing down hardwood stairs wearing socks and falls hard onto the stairs injuring his back. He is having a lot of trouble walking because of right-sided low back pain that radiates up his back and down to his thigh when he tries to stand. He says he took two ibuprofen at home without relief. He denies any neck pain, head injury, or other injuries or complaints. He takes no regular medication and has no prior medical conditions. He has a friend at the bedside who drove him to the ED.

On physical examination vital signs are all normal except for his blood pressure, which is elevated at 147/81 mm Hg, most likely a result of pain. His head and neck are non-tender and atraumatic. The upper back is non-tender, however he is tender in the lower back, more so on the right side with a slight abrasion. His neurovascular examination is intact.

You order spinal films. The lateral view is normal. The AP view is shown in the Figure, at right.

Do you see anything wrong? (Click on image to enlarge and look carefully)

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