What is the next step in management for a patient whose thoracic and lumbosacral spine X‑ray shows no acute fracture or significant spondylolisthesis, a mild T12 compression deformity without retropulsion, moderate bone demineralization, and multilevel degenerative changes?

Next Step in Management

Order MRI of the thoracic and lumbar spine without contrast to evaluate the T12 compression deformity for acuity, assess for occult fractures, and guide osteoporosis treatment decisions. 1

Rationale for MRI as the Next Step

The X-ray findings reveal several concerning features that require further characterization before determining definitive management:

• MRI with STIR (short-tau inversion recovery) sequences is the modality of choice to determine whether the T12 compression deformity is acute versus chronic, which is critical for treatment planning. 2, 3

• Standard radiographs and CT scans have a 23% misdiagnosis rate for single vertebral fractures and a 65% misdiagnosis rate for multiple fractures when compared to MRI with STIR sequencing, making MRI essential before any intervention. 3

• MRI is superior to plain radiographs for detecting occult compression fractures and marrow edema in patients with moderate bone demineralization, which this patient demonstrates. 4

• The presence of "moderate bone demineralization" on X-ray is a red flag that warrants advanced imaging to exclude additional acute fractures not visible on plain films and to assess for underlying causes such as malignancy or infection. 1

Specific MRI Protocol Recommendations

• Request MRI thoracic and lumbar spine without IV contrast as the initial study, since contrast is not typically needed to assess compression fractures unless infection or malignancy is strongly suspected. 1

• STIR sequences are essential to identify bone marrow edema, which indicates acute fracture and helps determine which levels require intervention if cement augmentation is considered. 3

• If the MRI demonstrates hyperintensity on T2-STIR sequences at T12, this confirms an acute fracture that may benefit from vertebroplasty or kyphoplasty if conservative management fails. 5

Concurrent Osteoporosis Evaluation and Treatment

While awaiting MRI results, initiate the following:

• Order DEXA scan to quantify bone mineral density and formally diagnose osteoporosis, as "moderate bone demineralization" on X-ray is a qualitative finding that requires objective measurement. 5

• Initiate pharmacologic osteoporosis treatment (e.g., bisphosphonates such as alendronate) if DEXA confirms osteoporosis (T-score ≤ -2.5), as treatment of the underlying osteoporosis is crucial to prevent future fractures. 6, 5

• Assess for secondary causes of osteoporosis including vitamin D deficiency, hyperparathyroidism, hyperthyroidism, and malignancy, particularly given the presence of a compression deformity. 5

Treatment Algorithm Based on MRI Findings

If MRI shows acute T12 fracture (hyperintense on STIR):

• Conservative management is first-line if the fracture is non-displaced and minimally painful: analgesics, back brace, and activity modification for 6-12 weeks. 5, 2

• Vertebroplasty or kyphoplasty should be considered if pain is severe and refractory to conservative treatment for 2-6 weeks, or if progressive vertebral collapse occurs. 5, 2

• Surgical intervention with instrumentation is indicated only if neurological deficits develop or if there is progressive kyphotic deformity with spinal instability. 5

If MRI shows chronic T12 fracture (no marrow edema):

• Focus on osteoporosis treatment and monitoring for new fractures, as the chronic deformity itself does not require intervention unless causing progressive deformity or neurological compromise. 5

• Physical therapy and core strengthening to prevent further fractures and improve functional status. 2

If MRI reveals multilevel acute fractures or suspicious features:

• Consider malignancy workup including CT chest/abdomen/pelvis, serum protein electrophoresis, and possible biopsy if lesions appear lytic or destructive. 1

• Evaluate for infection if there are epidural collections, endplate irregularity, or paraspinal soft tissue changes. 1

Common Pitfalls to Avoid

• Do not proceed with vertebroplasty or kyphoplasty based on X-ray findings alone, as plain films cannot reliably distinguish acute from chronic fractures, and treating chronic fractures with cement augmentation provides no benefit. 3

• Do not assume the T12 deformity is the only fracture in a patient with moderate osteoporosis; MRI frequently reveals additional occult fractures that alter management. 3

• Do not delay osteoporosis treatment while pursuing imaging; initiating calcium, vitamin D, and bisphosphonates (if no contraindications) can begin immediately. 6, 5

• Do not order thoracic spine X-rays for follow-up of known compression fractures; MRI is required to assess healing and guide intervention decisions. 4