In a patient with a suspected spinal compression fracture, is MRI (magnetic resonance imaging) preferred over CT myelogram (computed tomography myelography)?

MRI is Preferred Over CT Myelogram for Compression Fractures

For patients with suspected spinal compression fractures, MRI without IV contrast is the preferred initial imaging modality, while CT myelography has no established role in the initial assessment of compression fractures. 1

Evidence-Based Reasoning

MRI as First-Line Imaging

The 2024 ACR Appropriateness Criteria explicitly states that MRI thoracic spine without IV contrast is the initial study of choice for patients with back pain and suspected compression fractures 1. MRI excels at:

• Determining fracture acuity through detection of bone marrow edema, which is critical for selecting patients who may benefit from interventions like vertebroplasty or kyphoplasty
• Distinguishing benign from malignant fractures by identifying abnormal marrow signal, convex posterior vertebral body borders, and extension into posterior elements 2
• Assessing spinal canal compromise from retropulsed fracture fragments
• Evaluating soft tissue structures including the spinal cord, ligaments, and intervertebral discs

CT Myelography Has No Role

The guidelines are unequivocal: "There is no relevant literature to support the use of CT myelography thoracic spine in the initial imaging assessment" of compression fractures 1. CT myelography requires lumbar puncture with intrathecal contrast injection, adding procedural risk and discomfort without providing diagnostic benefit for compression fracture evaluation 2.

When CT (Without Myelography) May Be Useful

Standard CT without IV contrast has limited but specific roles:

• Emergency room setting when MRI is unavailable or contraindicated 1
• Presurgical planning to delineate osseous anatomy and plan hardware trajectory 1
• Evaluating bony detail in complex fractures, though this doesn't require myelography 2

Alternative Imaging When MRI Cannot Be Obtained

If MRI is contraindicated or unavailable, consider:

• Bone scan with SPECT or SPECT/CT to identify fracture acuity and guide intervention decisions 1
• Standard CT without contrast for fracture detection, though it cannot assess acuity 1

Clinical Algorithm

1. Initial imaging: MRI spine without IV contrast
2. Add IV contrast only if malignancy, infection, or inflammation suspected 1
3. If MRI contraindicated: Bone scan with SPECT/CT for acuity assessment
4. Reserve CT without contrast for presurgical planning or emergency situations when MRI unavailable
5. Never use CT myelography for compression fracture evaluation

Critical Pitfalls to Avoid

• Do not order CT myelography for compression fractures—it adds invasive risk without diagnostic benefit
• Do not rely on CT alone to determine fracture acuity; bone marrow edema visible only on MRI determines whether fractures are acute and potentially treatable with vertebral augmentation
• Do not skip contrast on MRI if there's any clinical suspicion of underlying malignancy or infection, as this significantly impacts management 1, 2