Is a computed tomography (CT) scan indicated for a stable compression fracture?

CT Scan for Stable Compression Fractures

CT scan is generally not indicated for stable compression fractures when radiographs adequately demonstrate the fracture and there are no concerning features requiring further evaluation. 1

Initial Imaging Approach

• Radiography is the appropriate first-line imaging for suspected vertebral compression fractures, particularly in patients with osteoporosis or steroid use. 1
• Plain radiographs with anteroposterior and lateral views are useful for assessing compression fractures in patients with low suspicion of trauma or minor trauma. 1
• Upright radiographs provide functional information about axial loading, and flexion-extension views can evaluate spine stability. 1

When CT Is NOT Needed

• For truly stable compression fractures without neurological deficits, CT adds unnecessary radiation exposure and cost without changing management. 2
• A 2019 study found that 29.3% of compression fracture workups included extraneous CT scans, causing an average of 979.4 mGy cm additional radiation exposure without clinical benefit. 2
• When radiographs clearly show a simple compression fracture and MRI or bone scan can determine acuity, CT becomes redundant. 2

When CT IS Indicated

CT should be obtained when there are concerns about:

• Posterior column involvement or instability - CT provides detailed analysis of fractures extending to the posterior column, pedicle integrity, and posterior cortex. 1
• Retropulsion of bone fragments - CT is superior for detecting displaced or retropulsed fractures that may compromise the spinal canal. 1, 3
• Neurological deficits - When patients have neurological compromise, CT helps evaluate the extent of canal compromise and posterior element disruption. 3
• Trauma mechanism suggesting instability - High-energy trauma or concerning fracture patterns warrant CT evaluation. 1

The Role of MRI vs CT

• MRI without contrast is the preferred advanced imaging modality for compression fractures when additional evaluation beyond radiographs is needed. 1, 4
• MRI is superior to CT for determining fracture acuity (bone marrow edema), distinguishing benign from pathologic fractures, and assessing spinal canal compromise. 1
• MRI provides diagnostic and prognostic information without radiation exposure. 1

Common Pitfalls

• Ordering CT reflexively without considering whether it will change management - Plain films are inadequate for determining stability (negative predictive value only 0.62), but this doesn't automatically mean CT is needed; MRI is often the better next step. 5
• Using CT to determine fracture chronicity - CT cannot determine if a fracture is acute or chronic; MRI or bone scan is required for this assessment. 2
• Failing to recognize that "stable" requires clinical correlation - A fracture appearing stable on radiographs may still warrant MRI to rule out ligamentous injury, posterior ligamentous complex disruption, or pathologic causes. 4

Recommended Algorithm

For suspected stable compression fracture:

1. Start with radiographs (AP and lateral, consider flexion-extension if stability questioned). 1
2. If radiographs confirm simple compression fracture without red flags (no neurological deficit, no posterior element involvement, appropriate clinical context), proceed with conservative management. 4, 6
3. If acuity determination needed, obtain MRI without contrast or bone scan - NOT CT. 2
4. Reserve CT for cases where:
   • Posterior column integrity must be assessed 1
   • Retropulsion or canal compromise is suspected 1
   • MRI is contraindicated or equivocal 1
   • Surgical planning requires detailed bony anatomy 3