From the Guidelines
Newly diagnosed compression fractures of T12 and L2 with increased metabolic activity are clinically significant and require further evaluation to determine the underlying cause and exclude the possibility of a pathologic fracture due to malignancy or infection.
Key Considerations
- The presence of vertebral fractures, particularly in the thoraco-lumbar transition (T12-L2 region), is a significant risk factor for future fractures and morbidity 1.
- Vertebral fracture assessment is essential in identifying the presence of vertebral fractures and assessing the risk of future fracture 1.
- The absence of hypermetabolic lymphadenopathy or other focal abnormalities does not rule out the possibility of an underlying metabolic bone disease or other contributing factors for osteoporosis 1.
Evaluation and Management
- Further clinical evaluation is necessary to exclude underlying causes of osteoporosis or metabolic bone disease, and to initiate appropriate treatment 1.
- Laboratory investigations, such as those listed in Table 4 of 1, may be necessary to exclude underlying causes of osteoporosis.
- Consideration of falls and osteosarcopenia is also essential, as they are associated with an increased risk of fracture 1.
- Referral to a specialized center may be appropriate in complex cases, particularly in premenopausal women or younger men with fragility fractures 1.
- Medical management and MRI spine area of interest without IV contrast or CT spine area of interest without IV contrast is usually appropriate for patients without known malignancy with new symptomatic compression fracture identified on radiographs or CT 1.
From the Research
Clinical Significance of Compression Fractures
The clinical significance of newly diagnosed compression fractures of T12 and L2 with increased metabolic activity can be understood by analyzing the provided evidence.
- The presence of increased metabolic activity in compression fractures can be indicative of malignant involvement, as shown in a study by 2 that used fluorodeoxyglucose positron emission tomography (FDG-PET) to differentiate between benign and malignant compression fractures.
- However, the absence of hypermetabolic lymphadenopathy or other focal abnormalities suggests that the fractures may be benign, as malignant fractures often present with additional metabolic activity in surrounding tissues 2.
- A study by 3 found that certain vertebrae, including T12, are more prone to fracture, and that the majority of fractures occur spontaneously or after trivial strain.
- The use of magnetic resonance imaging (MRI) features, such as convex posterior border of the vertebral body and involvement of the pedicle or posterior element, can help differentiate between malignant and benign compression fractures, as shown in a study by 4.
- Additionally, the presence of a fluid sign on MRI, which is characterized by signal intensity isointense to that of cerebrospinal fluid, can be an indicator of osteoporotic fractures, as demonstrated in a study by 5.
- A study by 6 analyzed the biomechanical comparison of wedge and biconcave deformity of different height restoration after augmentation of osteoporotic vertebral compression fractures, which may provide insight into the potential consequences of compression fractures on spinal stability.
Diagnostic Considerations
When diagnosing compression fractures, it is essential to consider the following:
- The clinical profile of the patient, including the presence of osteoporosis, previous history of fractures, and symptoms such as radiation to the flanks and anteriorly 3.
- The use of imaging modalities, such as FDG-PET and MRI, to differentiate between benign and malignant fractures 2, 4.
- The presence of specific MRI features, such as the fluid sign, which can indicate osteoporotic fractures 5.
- The potential for false-positive results on FDG-PET, particularly in patients who have undergone prior treatment with bone marrow-stimulating agents 2.