When is a computed tomography (CT) scan indicated for patients with compression fractures?

Indications for CT in Patients with Compression Fractures

CT scans are indicated for patients with compression fractures when there is suspicion of malignancy, cortical disruption, or when surgical planning is required, but are generally not necessary for routine evaluation of osteoporotic compression fractures.

Primary Indications for CT in Compression Fractures

Suspected Malignancy

• CT is valuable when there are concerns about malignant etiology of compression fractures 1
• CT provides high-detail imaging of bone cortex and trabeculae that can help identify:
  • Destruction of the anterolateral or posterior cortex (100% accuracy for malignancy)
  • Destruction of cancellous bone (97.4% accuracy for malignancy)
  • Destruction of end plates or pedicles
  • Presence of paraspinal or epidural masses 2

Surgical Planning

• CT without IV contrast is useful for presurgical planning, particularly when:
  • Hardware placement is being considered
  • Assessment of fracture comminution is needed
  • Evaluation of bony anatomy is required for trajectory planning 1

Equivocal Cases

• When MRI results are equivocal or contraindicated 1
• When there is a need to assess for articular surface collapse or sclerosis that could indicate secondary necrosis 1

When CT is NOT Indicated

Routine Osteoporotic Fractures

• CT does not aid in determining compression fracture chronicity and contributes to higher cost and radiation exposure 3
• For routine osteoporotic compression fractures, MRI without IV contrast or bone scan is preferred over CT to determine fracture acuity 1
• In 29.3% of cases, patients undergo extraneous CT scans during workup, causing unnecessary radiation exposure (average 979.4 mGy cm additional radiation) 3

Recommended Imaging Algorithm for Compression Fractures

1. Initial Imaging: Radiographs of the thoracic/lumbar spine

   • Useful for assessing LBP in patients with low suspicion of trauma or minor trauma 1
   • Upright radiographs provide functional information about axial loading 1

2. If radiographs are positive but acuity is uncertain:

   • MRI without IV contrast (preferred) 1
   • OR bone scan with SPECT or SPECT/CT if MRI is contraindicated 1

3. When to use CT:

   • Suspicion of malignancy based on clinical presentation or radiographic findings 1, 2
   • Need for surgical planning 1
   • When MRI is contraindicated and detailed bony anatomy is required 1

Special Considerations

Elderly Patients with Osteoporosis

• Elderly (>65 years) individuals, those with known osteoporosis, prior benign compression fracture, or chronic steroid use are at risk for additional compression fractures even with minimal trauma 1
• For these patients, MRI without IV contrast is typically preferred over CT to assess fracture acuity 1

Malignancy Detection

• If malignancy is suspected, MRI without and with IV contrast is considered superior for evaluating and localizing disease 1
• CT can be used to evaluate osseous integrity (e.g., pathologic fracture) when involved with tumor, but intradural and spinal cord pathologies are poorly depicted 1

Pitfalls to Avoid

1. Missing compression fractures on routine abdominal CT:

   • 84% of vertebral compression fractures may go unreported on abdominal CT if sagittal reconstructions are not evaluated 4
   • Consider routine evaluation of sagittal reconstructions in at-risk patients

2. Overreliance on CT for fracture acuity:

   • CT alone cannot reliably determine fracture acuity without advanced radiomic analysis 5
   • MRI remains the gold standard for determining fracture acuity 1

3. Unnecessary radiation exposure:

   • Avoid routine CT in addition to MRI or bone scan for standard osteoporotic compression fractures 3
   • Follow an algorithm that favors radiographs with comparison studies or MRI/bone scan to determine acuity 3

By following these evidence-based guidelines, clinicians can optimize the use of CT in the evaluation of compression fractures while minimizing unnecessary radiation exposure and healthcare costs.