Vertebral osteomyelitis may be considered in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers (ie, erythrocyte sedimentation rate), or bacteremia without a known extravertebral focus of infection, particularly if the patient is immunocompromised. Importantly, acute benign VCFs can be a source of false positive findings due to increased FDG uptake in the acute phase; however, the increased activity should return to normal in 3 months from the fracture date. If there is a failure of increased PET FDG activity in a VCF to return to normal by 3 months, clinical suspicion for malignancy or infection should remain high [65]. Variant 2: New symptomatic VCF identified on radiographs. History of malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging. For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the acuity or cause of the vertebral fracture [38]. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with Vertebral Compression Fractures cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression. Comparison to prior imaging is helpful to determine acuity. The presence of lobulated paraspinal masses with involvement of both vertebral body and posterior elements at the same time favors malignant involvement [66].
Management of Vertebral Compression Fractures PCAs. Vertebral osteomyelitis may be considered in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers (ie, erythrocyte sedimentation rate), or bacteremia without a known extravertebral focus of infection, particularly if the patient is immunocompromised. Importantly, acute benign VCFs can be a source of false positive findings due to increased FDG uptake in the acute phase; however, the increased activity should return to normal in 3 months from the fracture date. If there is a failure of increased PET FDG activity in a VCF to return to normal by 3 months, clinical suspicion for malignancy or infection should remain high [65]. Variant 2: New symptomatic VCF identified on radiographs. History of malignancy. Next imaging study. The body regions covered in this clinical scenario are the cervical, thoracic, and lumbar spine. These body regions might be evaluated separately or in combination, guided by physical examination findings, patient history, and other available information, including prior imaging. For some authors, focal tenderness upon palpation in correlation with radiographs of the vertebral column is a satisfactory indication for intervention. However, spine radiographs are often nonspecific with respect to the acuity or cause of the vertebral fracture [38]. CT Spine Area of Interest CT provides osseous details of axial spine fractures before VA [12,39]. CT permits evaluation of vertebral body height, architecture, and integrity of the posterior cortex and pedicles before VA, which is critical in patients with Vertebral Compression Fractures cortical disruption, posterior cortex osseous retropulsion, epidural extension, and spinal canal compression. Comparison to prior imaging is helpful to determine acuity. The presence of lobulated paraspinal masses with involvement of both vertebral body and posterior elements at the same time favors malignant involvement [66].