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Department of Orthopaedic Surgery, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
Department of Diagnostic Radiology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
ABSTRACT
Purpose. To evaluate the sensitivity, specificity
and accuracy of various magnetic resonance
imaging (MRI) features in differentiating vertebral
compression fractures caused by malignancy,
osteoporosis, and infections.
Methods. 35 men and 45 women aged 40 to 78
(mean, 59) years underwent MRI to assess the
underlying pathology of already diagnosed vertebral
compression fractures (n=152). The interval from
presentation to imaging ranged from 7 to 95 (mean,
62) days. MRI features of each vertebral compression
fracture were assessed. The sensitivity, specificity, and
accuracy for each of the MRI features were calculated.
Association between each MRI feature and various
underlying pathologies (malignancy, osteoporosis,
and infections) of vertebral compression fractures
was evaluated.
Results. Regarding these 80 patients, the MRI
diagnosis was correct in 78 and inconclusive in
2 with malignancy. MRI features suggestive of
INTRODUCTION
Vertebral
compression
fractures
are
common,
Address correspondence and reprint requests to: Dr ME Abdel-Wanis, Department of Orthopaedic Surgery, Sohag Faculty of
Medicine, Sohag, PO 82524, Egypt. E-mail: wanis307@yahoo.com
146 ME Abdel-Wanis
Table 1
Diagnoses of vertebral compression fractures based on
magnetic resonance imaging (MRI)
Diagnostic
result
Correct
Inconclusive
Incorrect
Osteoporotic
fractures
Infective
fractures
48 (96)
2 (4)
0
16 (100)
0
0
14 (100)
0
0
Table 2
Primary tumour diagnoses of 50 patients presented with 85
malignant vertebral compression fractures
Tumour origin
Breast
Myeloma
Liver
Lung
Lymphoma
Prostate
Thyroid
Kidney
Colon
Uterus
Unknown
Total
No. (%) of
patients
No. (%) of
fractures
13 (26)
7 (14)
4 (8)
4 (8)
4 (8)
4 (8)
3 (6)
2 (4)
1(2)
1(2)
7 (14)
50 (100)
29 (34)
12 (14)
4 (5)
8 (9)
8 (9)
4 (5)
5 (6)
2 (2)
1 (1)
3 (4)
9 (11)
85 (100)
MRI for differentiating malignant, osteoporotic, and infective vertebral compression fractures 147
Table 3
Magnetic resonance imaging (MRI) features suggestive of malignant, osteoporotic, and infective vertebral compression
fractures
MRI feature
Malignant fractures
Convex posterior border
Pedicle involvement
Posterior elements involvement
Epidural mass
Paraspinal mass
Other spinal metastases
Osteoporotic fractures
Retropulsion
Low signal intensity band
Spared normal marrow signal
intensity
Fluid sign
Infective fractures
Contiguous vertebral involvement
End plate disruption
Disc involvement
Paraspinal abscess
Epidural abscess
Osteoporotic
(n=34)
p Value
Infective
(n=33)
60 (71)
81 (95)
61 (72)
51 (60)
68 (80)
65 (77)
1 (3)
5 (15)
0
0
4 (12)
0
0
15 (46)
9 (27)
0
5 (15)
0
<0.0001
<0.0001
<0.0001
<0.0001
-
71
95
72
60
80
77
99
70
87
100
87
100
83
84
78
78
83
87
0
8 (9)
6 (7)
18 (53)
28 (82)
27 (79)
2 (6)
2 (6)
6 (18)
<0.0001
<0.0001
<0.0001
53
82
79
98
92
90
88
90
88
2 (2)
12 (35)
<0.0001
35
98
84
20 (24)
4 (5)
2 (2)
0
0
12 (35)
0
0
0
0
<0.0001
<0.0001
<0.0001
-
88
82
97
85
73
73
97
98
100
100
76
93
98
97
94
RESULTS
Regarding these 80 patients, the MRI diagnosis was
correct in 78 and inconclusive in 2 with malignancy
(Table 1).
In 50 patients, the underlying pathology of 85
vertebral compression fractures was malignancy
(Table 2). In 45 of them, the final diagnosis was
confirmed histopathologically through open biopsy.
In the remaining 5, it was based on progressive
deterioration of the fractured vertebra and/or new
development of spinal metastases evident with followup MRI. Indications for surgery were interactable
pain, neurological deficits, and a confirmed tissue
diagnosis.
In 16 patients, the underlying pathology of 34
vertebral compression fractures was osteoporosis. In
14 of them, the final diagnosis was based on clinical
and radiological follow-up over 6 to 12 months. In
the remaining 2, it was confirmed histopathologically.
Indication for surgery was neurological deficits.
In 14 patients, the underlying pathology of 33
vertebral compression fractures was infection. Their
final diagnoses were confirmed histopathologically.
The indications for surgery were interactable pain,
severe or progressive kyphosis, a large abscess, and
spinal instability.
MRI features suggestive of malignant fractures
were a convex posterior border of the vertebral
body, pedicle involvement, posterior neural element
involvement, an epidural mass, a paraspinal mass,
and other spinal metastases (Table 3 and Fig. 1).
29 (88)
27 (82)
32 (97)
28 (85)
24 (73)
148 ME Abdel-Wanis
(a)
(b)
(c)
(d)
Figure 1 (a) Sagittal T1-weighted, (b) T2-weighted (c) short T1 inversion recovery, and (d) axial (L5) T2-weighted magnetic
resonance images (MRI) of the lumbosacral spine in a 46-year-old woman: the compression fracture of the L5 vertebral body
shows complete replacement of normal marrow signal intensity, convex posterior border (arrows), involvement of the pedicles
and transverse processes (asterisk), and metastases affecting L3 and L4 vertebrae (arrowheads). The MRI diagnosis is metastases
affecting L3, L4, and L5 vertebrae complicated with compression fracture of L5. The final diagnosis is metastatic compression
fracture of L5 originating from breast cancer.
(a)
(b)
(c)
(d)
Figure 2 Sagittal (a) T1-weighted, (b) T2-weighted, (c) short T1 inversion recovery, and (d) axial (L2 and L3) T2-weighted
magnetic resonance images (MRI) of the lumbosacral spine in a 60-year-old woman: compression fractures of L2 and L3 show
anterior wedging of the L2 vertebral body, low signal fracture line at L2 and L3, fluid sign at L3, and incomplete replacement
of normal marrow signal intensity. The MRI diagnosis is L2 and L3 acute osteoporotic compression fractures, which is also the
final diagnosis.
(a)
(e)
MRI for differentiating malignant, osteoporotic, and infective vertebral compression fractures 149
(b)
(c)
(f)
(d)
(g)
Figure 3 Sagittal (a) T1-weighted, (b) T1-weighted after gadolinium-diethylenetriamine pentacetic acid (Gd-DTPA) injection,
(c) T2-weighted, (d) short T1 inversion recovery, and axial (e) T1-weighted, (f) T1-weighted after Gd-DTPA injection, (g) T2weighted magnetic resonance images (MRI) of the thoracic spine in a 54-year-old woman: compression fractures of T5 and T6
show contiguous vertebral involvement, complete replacement of normal bone marrow signal intensity, involvement of both
pedicles (arrows), intervening disc involvement, and an encasing epidural mass and multiple paraspinal masses (arrowhead).
The MRI diagnosis is spondylodiscitis affecting T5 and T6 and intervening disc complicated with vertebral compression fractures.
The final diagnosis is compression fractures of T5 and T6 caused by tuberculosis infection (Potts disease).
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