What type of MRI should be ordered for an L1 compression fracture, with or without contrast?

MRI Lumbar Spine Without Contrast for L1 Compression Fracture

For an L1 compression fracture, order an MRI lumbar spine WITHOUT contrast as your initial study. 1

Primary Recommendation

• MRI without IV contrast is the preferred initial imaging modality for evaluating L1 compression fractures, as it effectively determines fracture acuity through bone marrow edema detection, demonstrates spinal canal compromise, and distinguishes between malignant and benign compression fractures. 1

• The non-contrast sequences provide excellent visualization of the convex posterior vertebral body border, extension into posterior elements, and abnormal marrow signal—all critical features for assessing pathologic versus osteoporotic fractures. 1

When to Add Contrast

Add contrast (MRI without AND with IV contrast) only if you have specific clinical red flags:

• Suspected underlying malignancy or metastatic disease: When there is a history of cancer or clinical concern for pathologic fracture, contrast helps delineate tumor extent and assess epidural involvement. 1

• Suspected infection: If there are signs of osteomyelitis, discitis, or epidural abscess, contrast with fat suppression is invaluable for identifying epidural and paraspinal abscesses and distinguishing abscess from phlegmon. 1

• Immunosuppression: Patients who are immunocompromised warrant contrast-enhanced imaging to evaluate for occult infection or atypical malignancy. 1

• Inflammatory conditions: When there is clinical suspicion for inflammatory spondyloarthropathy or other inflammatory processes. 1

Clinical Decision Algorithm

Step 1: Assess for red flags

• History of cancer, unexplained weight loss, fever, immunosuppression, or IV drug use? → MRI without AND with contrast 1

Step 2: If no red flags present

• Osteoporosis, advanced age (>65), chronic steroid use, or low-velocity trauma? → MRI without contrast 1

Step 3: Evaluate neurologic status

• Neurologic deficit or myelopathy present? → MRI without contrast remains appropriate initially, though CT myelography can be considered if MRI is contraindicated. 1

Important Caveats

• Contrast alone (without non-contrast sequences) should never be ordered as an initial study, since interpretation requires correlation with standard non-contrast sequences. 1

• Radiographs may be obtained first in patients with osteoporosis or steroid use for initial screening, but note that thoracic/lumbar vertebral fractures on radiographs are difficult to date without prior films for comparison—MRI is needed to determine fracture acuity. 1

• CT without contrast provides detailed fracture analysis for surgical planning (posterior column involvement, pedicle integrity) but is inferior to MRI for assessing bone marrow edema, fracture acuity, and distinguishing benign from malignant etiology. 1

• Bone scan with SPECT/CT can help identify fracture acuity when MRI cannot be safely obtained, but this is not a first-line study. 1

Practical Considerations

• MRI without contrast effectively shows bone marrow edema, which is the key finding for determining if a compression fracture is acute/subacute versus chronic. 1

• The distinction between malignant and benign compression fractures can be reliably assessed on non-contrast MRI by evaluating vertebral body morphology, posterior element involvement, and marrow signal characteristics. 1

• If initial MRI without contrast is indeterminate for malignancy or infection, you can always add a subsequent contrast-enhanced study rather than starting with both. 1