What is the appropriate evaluation and management for compression deformities of the T12 and L2 vertebral bodies of indeterminate chronicity on imaging?

Evaluation and Management of T12 and L2 Compression Deformities of Indeterminate Chronicity

When compression fractures at T12 and L2 are identified on imaging but their chronicity is uncertain, obtain MRI with fluid-sensitive sequences (STIR or fat-saturated T2) to determine if the fractures are acute and compare with prior imaging when available to establish chronicity. 1

Initial Diagnostic Approach

Determine Fracture Acuteness

• MRI is the definitive modality to distinguish acute from chronic compression fractures when chronicity cannot be determined on plain radiographs or CT 1, 2
• Fluid-sensitive sequences (STIR or fat-saturated T2-weighted imaging) detect bone marrow edema indicating acute fractures 1
• Compare with pre-existing images whenever possible to confirm whether compression fractures are chronic or new 1
• MRI should include T2-weighted and gradient-echo sequences to fully characterize the fracture and assess for complications 1

Clinical Correlation

• Perform closed-fist percussion of the spine at the fracture levels—this sign has 87.5% sensitivity and 90% specificity for acute fractures 3
• Ask the patient to lie supine on the examination couch—inability or severe pain with this maneuver has 81.25% sensitivity and 93.33% specificity for acute fractures 3
• Document presence of new back pain, height loss, or neurological symptoms 1

Exclude Pathologic Causes

When to Suspect Malignancy

• MRI with and without IV contrast is imperative if there is history of malignancy or atypical clinical features 1
• Look for these malignant features on imaging: convex posterior vertebral body margin, abnormal signal in the pedicles or posterior elements, epidural or paraspinal soft tissue mass, and multiple noncontiguous levels 4
• Additional imaging with conventional radiographs may be indicated for sclerotic or lytic changes, or findings suggesting conditions other than osteoporosis 1

Consider Infection

• FDG-PET/CT can localize metabolic activity in areas of spinal infection if vertebral osteomyelitis is suspected 1
• Consider infection in the setting of severe back pain, persistent unexplained fever, elevated inflammatory markers, or bacteremia 1

Assess for Neurological Compromise

• MRI is essential if there are symptoms or signs of spinal cord, conus medullaris, or nerve root injury 1
• Evaluate for cord compression from disc herniation, bone fragments, or hematomas 1
• The examination should include T2-weighted and gradient-echo images to assess for cord injury 1

Management Algorithm Based on Fracture Acuteness

If Acute Fractures Are Confirmed

Conservative Management (First-Line):

• Medical management with analgesics and osteoporosis treatment 1, 2
• Bracing may be considered 2
• Physical therapy once acute pain subsides 2

Vertebral Augmentation Indications:

• Consider vertebroplasty or kyphoplasty for patients with persistent severe pain despite 6 weeks of optimal medical management 1
• Both procedures are equally effective for pain relief and have similar complication rates 1
• Vertebral augmentation can be performed even for fractures >12 weeks old if they remain symptomatic 1

If Chronic Fractures Are Confirmed

• Focus on osteoporosis management and fall prevention 1
• Obtain DXA scan if not recently performed to assess bone mineral density and guide osteoporosis treatment 1
• Consider vertebral fracture assessment (VFA) to identify additional occult fractures 1

Additional Imaging Considerations

When Standard Imaging Is Inadequate

• Tc-99m SPECT/CT can more precisely localize abnormalities in complicated cases with multiple collapsed vertebrae of different ages, showing 63-80% agreement with MRI 1
• Bone scan may help determine which vertebral level is causing pain, particularly in single-level fractures 1

Assess for Associated Injuries

• Evaluate for vertebral endplate injury (present in 68% of acute osteoporotic fractures) and adjacent intervertebral disk injury (present in 51% of cases) 5
• Superior endplate injury (39%) is more common than inferior endplate injury (12%) 5
• These associated injuries are frequently under-reported but may have important implications for symptoms and outcomes 5

Common Pitfalls to Avoid

• Do not rely on plain radiographs or CT alone to determine fracture chronicity—they cannot distinguish acute from chronic fractures 3, 2
• Many imaging abnormalities can be seen in asymptomatic individuals; among patients ≥65 years with vertebral fractures, only 38% have osteoporosis by BMD criteria 1
• Vertebral levels not adequately visualized on VFA should not be included in analysis and should be noted as exclusions 1
• When there are two or more mild (grade 1) deformities without moderate or severe deformities, additional imaging with conventional radiographs may be indicated 1