Diagnostic Approach for Vertebral Compression Fractures

Initial Evaluation

The American College of Radiology recommends starting with anteroposterior and lateral radiographs of the spine as the first-line imaging study for suspected vertebral compression fractures, particularly in patients with osteoporosis or chronic steroid use 1, 2, 3
Upright radiographs provide functional information about axial loading and can identify new compression fractures when compared to prior films, with the American College of Radiology suggesting their use 1, 2
Flexion and extension views can evaluate spine stability, as recommended by the American College of Radiology 1, 2

The American College of Radiology suggests proceeding to MRI of the affected spine region without IV contrast if radiographs confirm a compression fracture or if clinical suspicion remains high despite negative radiographs [1, 2, 4, 5 is ignored as per instruction]
STIR or fat-saturated T2-weighted sequences are crucial for showing bone marrow edema that indicates an acute/unhealed fracture, according to the American College of Radiology and the Journal of Neurointerventional Surgery 1, 4, 6
T1-weighted sequences identify fracture clefts and assess overall vertebral body integrity, as identified by the Journal of Neurointerventional Surgery and the American College of Radiology 4, 6
MRI distinguishes benign osteoporotic fractures from pathologic fractures by identifying specific characteristics, such as convex posterior vertebral body border and abnormal marrow signal patterns, as noted by the American College of Radiology 1, 2

The American College of Radiology recommends upgrading to MRI with IV contrast when there is clinical suspicion of underlying malignancy, infection, or inflammation 1, 2
Known history of cancer is a red flag indication for contrast-enhanced MRI, as suggested by the American College of Radiology 1, 2
Unexplained fever, elevated inflammatory markers, or bacteremia suggesting vertebral osteomyelitis are also indications for contrast-enhanced MRI, according to the American College of Radiology and the Journal of Neurointerventional Surgery 6

The American College of Radiology suggests reserving CT spine without IV contrast for specific scenarios where MRI findings need clarification or MRI is contraindicated 1, 2
CT provides superior detail of fracture extension to the posterior column and pedicle integrity, as noted by the American College of Radiology 1, 2

The American College of Radiology recommends obtaining a complete blood count, erythrocyte sedimentation rate, and C-reactive protein if infection is suspected 1

FDG-PET/CT whole body is appropriate as a follow-up study to distinguish benign from pathologic compression fractures when MRI and CT are indeterminate, as suggested by the American College of Radiology 1, 2
For patients with known malignancy, MRI of the complete spine without and with IV contrast is the appropriate comprehensive study to evaluate for multiple metastatic lesions, according to the American College of Radiology 8, 7
The Spinal Instability Neoplastic Score (SINS) can be used to classify stability, with scores ranging from 0-6 (stable), 7-12 (potentially unstable), or 13-18 (unstable), as noted by the American College of Radiology 7

Point tenderness at the spinous process of the fractured vertebra is a classic finding, as identified by the Journal of Neurointerventional Surgery 9
A complete lower extremity neurological examination is essential, including motor strength, sensation, reflexes, and rectal tone, as recommended by the Journal of Neurointerventional Surgery and the American College of Radiology 4, 9