What should be ordered for a patient with a cerebral compression fracture and no cancer history?

Vertebral Compression Fracture Without Cancer History: Initial Imaging

For a patient presenting with a vertebral compression fracture and no cancer history, order MRI of the spine without IV contrast as the initial imaging study to determine fracture acuity, assess for spinal cord compression, and distinguish between benign osteoporotic and pathologic fractures. 1

Primary Imaging Recommendation

MRI spine without IV contrast is the preferred initial study because it:

• Demonstrates bone marrow edema to determine fracture acuity 1
• Identifies spinal canal compromise from displaced or retropulsed fracture fragments 1
• Distinguishes malignant from benign compression fractures by evaluating for convex posterior vertebral body border, extension into posterior elements, and abnormal marrow signal patterns 1
• Detects extrinsic spinal cord compression from epidural hematoma or other causes 1

Alternative Initial Imaging

If MRI is contraindicated or unavailable, CT spine without IV contrast is appropriate for:

• Detailed analysis of fractures extending to the posterior column 1
• Evaluating integrity of pedicles and posterior cortex 1
• Assessing for cauda equina impingement (equal to MRI for this purpose) 1

Critical Red Flags Requiring Immediate Action

Order MRI spine without AND with IV contrast if any of the following are present:

• Suspicion of underlying malignancy despite "no cancer history" (new diagnosis possible) 1
• Signs of infection (fever, elevated inflammatory markers) 1
• Progressive neurological deficits 1, 2
• Severe or worsening pain out of proportion to injury 1

The addition of IV contrast helps delineate etiology when clinical suspicion exists for malignancy, infection, or inflammation, even without known cancer history 1

When Plain Radiographs Are Sufficient

Initial radiography (AP and lateral views) is appropriate only if:

• Patient has known osteoporosis or chronic steroid use 1
• Low suspicion for acute neurological compromise 1
• Used as a screening tool before advanced imaging 1

However, radiography has significant limitations: at least 50% of bone must be eroded before changes are visible, making it inadequate for detecting early pathologic processes 1

Additional Imaging Considerations

FDG-PET/CT whole body is not an initial study but can be ordered as follow-up if:

• MRI findings are indeterminate for distinguishing benign versus pathologic fracture 1
• Concern for widespread metastatic disease despite no known cancer history 1

CT myelography may be useful if:

• Patient has neurological deficit with osteoporotic fracture 1
• MRI is contraindicated and detailed assessment of neural compression is needed 1

Common Pitfalls to Avoid

• Do not assume "no cancer history" means benign fracture: New malignancy can present as pathologic fracture, and only history of cancer has been shown to increase probability of finding spinal malignancy 1
• Do not delay MRI if neurological symptoms present: Even minor neurological changes require urgent evaluation for spinal cord compression 1, 2
• Do not order MRI with contrast alone: If contrast is needed, always order without AND with contrast, as interpretation requires correlation with noncontrast sequences 1
• Do not rely on radiographs alone in trauma or acute presentation: They miss early pathologic changes and provide limited assessment of vertebral body comminution, especially in osteoporosis 1