Image Challenge

An 80-year-old female with osteoporosis presented to the clinic in September 2026 reporting acute, severe, and spontaneous mid-to-lower back pain. Baseline dual-energy X-ray absorptiometry (DXA) in April 2022 demonstrated a T-score of -3.0 at the femoral neck, -2.8 at the total hip, and -3.2 at the lumbar spine (L1–L4). She had no prior history of fragility fractures. She had received denosumab 60 mg subcutaneously every 6 months for 6 doses between April 2022 and April 2025 (total exposure 7 doses). She was lost to follow-up because she felt well and did not receive her scheduled dose in October 2025 or any subsequent antiresorptive therapy. Approximately 17 months after her last denosumab injection, she developed sudden, debilitating thoracic and lumbar back pain without preceding trauma. Physical examination revealed 3 centimeters of height loss since the April 2025 visit, thoracic spine tenderness, and increased kyphosis compared with prior visits. Thoracolumbar radiographs were obtained (Figures 1 and 2).