Fluid-sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) can help detect fracture clefts and identify synchronous fractures [46,47]. IV contrast may yield beneficial information with increased homogenous and heterogenous enhancement patterns seen more in neoplastic fractures with or without associated enhancing paraspinal soft tissues. Enhancement involving the posterior elements raises the suspicion for malignancy further [66]. Diffusion and perfusion imaging are also used to help differentiate benign from malignant compression fractures with low apparent diffusion coefficient values and increased perfusion parameters, suggesting neoplastic over benign involvement [66]. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52] and also to evaluate other areas of metastases because of complete skeletal coverage, especially in a patient with a history of malignancy [53,54,58]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple-level involvement [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. Osteosclerotic bone metastases can be detected on bone scintigraphy up to 18 months earlier than on radiographs [72]. The utilization of bone scans may be based on institutional preference. SPECT or SPECT/CT Spine Area of Interest SPECT coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake.
Management of Vertebral Compression Fractures PCAs. Fluid-sensitive MRI sequences (short tau inversion recovery or fat-saturated T2-weighted imaging) can help detect fracture clefts and identify synchronous fractures [46,47]. IV contrast may yield beneficial information with increased homogenous and heterogenous enhancement patterns seen more in neoplastic fractures with or without associated enhancing paraspinal soft tissues. Enhancement involving the posterior elements raises the suspicion for malignancy further [66]. Diffusion and perfusion imaging are also used to help differentiate benign from malignant compression fractures with low apparent diffusion coefficient values and increased perfusion parameters, suggesting neoplastic over benign involvement [66]. Bone Scan Whole Body Tc-99m whole-body bone scan (bone scintigraphy) may be helpful to determine the painful vertebrae [52] and also to evaluate other areas of metastases because of complete skeletal coverage, especially in a patient with a history of malignancy [53,54,58]. Bone scan and MRI have higher concordance with single-level fractures compared with multiple-level involvement [55]. When more than one area of increased activity is detected, bone scans may overestimate the number of acute fractures. As such, multiple regions of radiotracer accumulation should be interpreted cautiously [56]. Osteosclerotic bone metastases can be detected on bone scintigraphy up to 18 months earlier than on radiographs [72]. The utilization of bone scans may be based on institutional preference. SPECT or SPECT/CT Spine Area of Interest SPECT coupled with CT provides complementary information because sites of abnormal radiopharmaceutical uptake on the spine are of interest. SPECT images can be anatomically localized on the CT, and anatomic abnormalities on CT images can draw attention to subtle areas of SPECT tracer uptake.