Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. The presence of intravertebral vacuum phenomenon favors a benign etiology [67]. IV contrast does not provide additional value in this clinical scenario. CT Myelography Spine Area of Interest CT myelography of the spine may be useful in patients in this clinical scenario because it can delineate the degree of thecal sac compression. Myelography is also obtained in patients with previous metal hardware to evaluate epidural disease and to accurately delineate the spinal cord for preirradiation treatment planning. MRI Spine Area of Interest MRI may provide valuable information to differentiate malignant from benign VCFs. Neoplastic VCFs often have a total replacement of the normally high T1 bone marrow signal intensity, resulting in diffuse homogeneous low signal intensity. In osteoporosis, the underlying mechanism leading to fracture is the loss of bone mineral density with preservation of the marrow [68]. Abnormal marrow signal involving the pedicles or other posterior elements is a strong indicator of malignancy in VCFs because tumor spread to the posterior elements typically occurs before tumor-associated structural instability leads to fracture within the vertebral body [65,69]. Although osteoporotic fractures can also have edema in the pedicles related to stress reaction, they infrequently have signal change in the posterior elements [65,69]. Abnormal epidural or paravertebral soft tissue is another imaging finding suggesting a pathologic VCF with convex retropulsion of the posterior cortex [70]. A bilobed appearance in the ventral extradural space is more commonly seen in neoplastic disease, as opposed to nonneoplastic disease, in which there is preservation of the strong attachment of the central sagittal septum [71].
Management of Vertebral Compression Fractures PCAs. Dual-energy CT may show bone marrow edema with reasonably high sensitivity and specificity [40,41] and good concordance to MRI in thoracolumbar VCFs [42]. The presence of intravertebral vacuum phenomenon favors a benign etiology [67]. IV contrast does not provide additional value in this clinical scenario. CT Myelography Spine Area of Interest CT myelography of the spine may be useful in patients in this clinical scenario because it can delineate the degree of thecal sac compression. Myelography is also obtained in patients with previous metal hardware to evaluate epidural disease and to accurately delineate the spinal cord for preirradiation treatment planning. MRI Spine Area of Interest MRI may provide valuable information to differentiate malignant from benign VCFs. Neoplastic VCFs often have a total replacement of the normally high T1 bone marrow signal intensity, resulting in diffuse homogeneous low signal intensity. In osteoporosis, the underlying mechanism leading to fracture is the loss of bone mineral density with preservation of the marrow [68]. Abnormal marrow signal involving the pedicles or other posterior elements is a strong indicator of malignancy in VCFs because tumor spread to the posterior elements typically occurs before tumor-associated structural instability leads to fracture within the vertebral body [65,69]. Although osteoporotic fractures can also have edema in the pedicles related to stress reaction, they infrequently have signal change in the posterior elements [65,69]. Abnormal epidural or paravertebral soft tissue is another imaging finding suggesting a pathologic VCF with convex retropulsion of the posterior cortex [70]. A bilobed appearance in the ventral extradural space is more commonly seen in neoplastic disease, as opposed to nonneoplastic disease, in which there is preservation of the strong attachment of the central sagittal septum [71].