EDUCATION EXHIBIT 179

RadioGraphics
Discrimination of
Metastatic from Acute
Osteoporotic Compres-
sion Spinal Fractures
with MR Imaging1
Hee-Sun Jung, MD ● Won-Hee Jee, MD ● Thomas R. McCauley, MD
Kee-Yong Ha, MD ● Kyu-Ho Choi, MD

A study was performed to determine which magnetic resonance (MR)

imaging findings are useful in discrimination between metastatic com-
pression fractures and acute osteoporotic compression fractures of the
spine. The MR imaging findings in 27 patients with metastatic com-
pression fractures and 55 patients with acute osteoporotic compression
fractures were compared by using the ␹2 test. MR imaging findings
suggestive of metastatic compression fractures were as follows: a con-
vex posterior border of the vertebral body, abnormal signal intensity of
the pedicle or posterior element, an epidural mass, an encasing epi-
dural mass, a focal paraspinal mass, and other spinal metastases. MR
imaging findings suggestive of acute osteoporotic compression frac-
tures were as follows: a low-signal-intensity band on T1- and T2-
weighted images, spared normal bone marrow signal intensity of the
vertebral body, retropulsion of a posterior bone fragment, and multiple
compression fractures. The signal intensity on fast spin-echo T2-
weighted images obtained without fat suppression played little role in
distinguishing between metastatic compression fractures and acute
osteoporotic compression fractures.
©
RSNA, 2003

Introduction
Atraumatic vertebral compression fractures in the thoracic or lumbar spine are a com-
mon clinical problem, particularly in elderly patients. Osteoporosis is the most com-
mon cause of compression fractures in this age group. The spine is a common site of
metastatic disease and accounts for up to 39% of all bone metastases. Such metastases
may result in a pathologic fracture (1). Compression fractures due to metastatic ma-
lignancy are frequently seen in the same age group, and differentiation from benign

Index terms: Osteoporosis, 30.56 ● Spine, fractures, 30.411 ● Spine, secondary neoplasms, 30.33

RadioGraphics 2003; 23:179 –187 ● Published online 10.1148/rg.231025043

1From the Departments of Diagnostic Radiology (H.S.J., W.H.J., K.H.C.) and Orthopedic Surgery (K.Y.H.), Catholic University of Korea, 505
Banpo-dong, Seocho-gu, Seoul 137-701, South Korea; and the Department of Diagnostic Radiology, Yale University School of Medicine, New Ha-
ven, Conn (T.R.M.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received March 1, 2002; revision requested May 10
and received June 17; accepted July 15. Address correspondence to W.H.J. (e-mail: whjee@cmc.cuk.ac.kr).
©
RSNA, 2003
 180 January-February 2003
RadioGraphics compression fractures due to osteoporosis often
affects appropriate clinical staging, treatment
planning, and prognostic determination in pa-
tients with known nonosseous malignancies (2).
Chronic benign compression fractures can be eas-
ily detected due to absence of abnormal signal
intensity in a compressed vertebra (2,3); however,
acute osteoporotic compression fractures can be
difficult to differentiate from malignant compres-
sion fractures.
In this article, we discuss magnetic resonance
(MR) imaging findings that are helpful in dis-
crimination between acute compression fractures
of the spine due to osteoporosis and compression
fractures of the spine due to metastasis.
Materials and Methods
MR images of 133 patients with vertebral com-
pression fractures who underwent MR imaging of
the spine during a 5-year period were retrospec-
tively reviewed by an experienced musculoskeletal
radiologist (W.H.J.) without knowledge of the
clinical history or pathologic results. The reviewer
evaluated the presence or absence of individual
imaging criteria as well as making an overall as-
sessment of the type of fracture. Collapsed verte-
brae were considered to be acute if there was a
recent history of back pain of less than 3 months
duration that was located at the same spinal level.
The final diagnosis was made on the basis of bi-
opsy results or results of clinical and radiologic
follow-up for at least 1 year. The malignant na-
ture of the fractures was established by progres-
sive deterioration of a fractured vertebra or newly
developed other spinal metastases at follow-up
MR imaging, computed tomography, bone scin-
tigraphy, or plain radiography. When the findings
of follow-up radiologic studies did not progress in
a patient without a clinical history of malignancy,
the fracture was considered to be a benign com-
pression fracture. Clinical parameters were pain,
laboratory findings such as serum alkaline phos-
phatase level, and the disease status of the pri-
mary neoplasm according to the treatment. After
chart review, 51 patients were excluded due to
chronic osteoporotic compression fractures (n ⫽
29) or a history of trauma (n ⫽ 22). Malignant
compression fractures included those due to me-
tastasis only. Measurement of bone mineral den-
sity was not performed in many of the patients
and therefore these data were not included.
The MR imaging findings in 27 patients with
metastatic compression fractures and 55 patients
with acute atraumatic osteoporotic compression
RG f Volume 23 ● Number 1
fractures were compared. The mean age of pa-
tients with metastatic compression fractures was
57 years (range, 35– 85 years); the mean age of
patients with acute osteoporotic compression
fractures was 69 years (range, 48 –92 years).
There were 19 men and eight women in the
group with metastatic compression fractures;
there were 15 men and 40 women in the group
with acute osteoporotic compression fractures.
The time from presenting complaint to MR imag-
ing was 3–91 days (mean, 32 days) in patients
with acute osteoporotic compression fractures.
Primary neoplasms included lung cancer (n ⫽ 5),
colorectal cancer (n ⫽ 5), stomach cancer (n ⫽
3), hepatocellular carcinoma (n ⫽ 3), breast can-
cer (n ⫽ 2), bladder cancer (n ⫽ 2), common bile
duct cancer (n ⫽ 1), laryngeal cancer (n ⫽ 1),
transglottic cancer (n ⫽ 1), prostate sarcoma (n ⫽
1), and unknown primary cancer (n ⫽ 3). Of the
27 metastatic fractures, two were confirmed with
biopsy and the remaining 25 cases were con-
firmed with radiologic and clinical follow-up.
MR imaging was performed with a 1.5-T im-
ager (Signa; GE Medical Systems, Milwaukee,
Wis) and a rectangular surface coil in 56 patients
and with a 1.5-T imager (Magnetom Vision; Sie-
mens, Erlangen, Germany) and a spine coil in 26
patients. Axial and sagittal T1-weighted images
(repetition time msec/echo time msec ⫽ 350 –
650/11–30) and fast spin-echo or turbo spin-echo
T2-weighted images (2,500 – 4,000/76 –108)
without fat saturation were obtained. In addition,
axial and sagittal fat-suppressed T1-weighted im-
ages (350 – 650/11–30) were obtained after intra-
venous administration of 0.1 mmol/kg gado-
pentetate dimeglumine except in one patient with
an acute osteoporotic compression fracture. Typi-
cal imaging parameters were as follows: field of
view, 15–20 cm for the axial plane and 30 –35 cm
for the sagittal plane; two signals averaged; matrix
size, 256 ⫻ 192; section thickness, 4 mm; inter-
section gap, 1 mm; and echo train length, eight to
11.
The signal intensity and enhancement patterns
of the compressed vertebrae as well as the pres-
ence of a low-signal-intensity band on T1- and
T2-weighted images and spared normal bone
marrow signal intensity of the vertebral body were
evaluated. In addition, the following findings
were evaluated: anterior or central compression
versus compression of all columns, convex poste-
rior border of the vertebral body, abnormal signal
intensity of the pedicle or posterior element, epi-
dural mass, encasing epidural mass encircling the
entire thecal sac, paraspinal mass (which was clas-
sified into focal irregular paraspinal mass and diffuse
 RG f Volume 23 ● Number 1 Jung et al 181

RadioGraphics

Figure 1. Typical metastatic compression fracture in a 65-year-old man. (a) Sagittal T1-weighted MR image
(400/11) shows a compression fracture with complete replacement of the normal bone marrow of the L1 verte-
bral body. A convex posterior cortex is present (arrows). There is a rounded metastatic focus within an adjacent
noncollapsed vertebral segment at the level above the compression fracture. (b) Sagittal fast spin-echo T2-
weighted MR image (3,000/96, echo train length of eight) shows that the L1 vertebral body is heterogeneously
hypointense (arrows). (c) Sagittal fat-suppressed contrast material– enhanced T1-weighted MR image (550/11)
shows homogeneous enhancement of the L1 vertebral body (arrows). The L1 vertebral body demonstrated het-
erogeneous enhancement on other sections. Note the enhancement of the metastatic focus at the vertebral level
above the compression fracture. (d) Axial fat-suppressed contrast-enhanced T1-weighted MR image (400/14)
shows a focal paraspinal mass (long arrows) and an anterior epidural mass (short arrows).

smooth paraspinal mass), other spinal metastasis, Differentiation of Metastatic

retropulsion of a posterior bone fragment, and the
presence of multiple compression fractures. Sig-
nal intensity in the marrow of abnormal vertebral
bodies was considered hypointense, isointense, or
hyperintense in comparison with the signal inten-
sity of normal vertebrae in the same patient on
T1- and T2-weighted images.
Univariate analysis with the ␹2 test and multi-
variate logistic regression analysis were performed
to study possible associations between MR imag-
ing findings and differentiation of metastatic from
acute osteoporotic compression fractures.
from Acute Osteoporotic Com-
pression Fractures with MR Imaging
Distinction between metastatic and acute osteo-
porotic compression fractures could be made on
the basis of MR imaging findings (Figs 1, 2). The
sensitivity, specificity, and accuracy for metastatic
compression fractures were 100%, 93%, and
95%, respectively. The overall diagnostic accu-
racy in the present study was comparable with
 182 January-February 2003 RG f Volume 23 ● Number 1

RadioGraphics

Figure 2. Typical acute osteoporotic compression

fracture in a 72-year-old woman. (a) Sagittal T1-
weighted MR image (400/12) shows compression frac-
tures of T12 and L1 with normal residual bone marrow
signal intensity in the vertebral bodies. Retropulsion of
a bone fragment (arrow) is present at the posterior por-
tions of the vertebral bodies. (b) Sagittal turbo spin-
echo T2-weighted MR image (3,200/99, echo train
length of 11) shows that the collapsed vertebral bodies
are relatively isointense to adjacent vertebrae. Hypoin-
tense bands (arrows) are present in the superior por-
tions of the collapsed vertebrae. (c) Sagittal fat-sup-
pressed contrast-enhanced T1-weighted MR image
(432/12) shows heterogeneous enhancement (arrows).
The low-signal-intensity bands are nonenhancing, but
there is rimlike enhancement around these regions.

that in previous reports (3–5), in which the sensi-

tivity, specificity, and accuracy were 85%–100%,
79%–100%, and 86%–95%, respectively. MR
imaging findings suggestive of metastatic com-
pression fracture were as follows: convex poste-
rior border of the vertebral body, abnormal signal
intensity of the pedicle or posterior element,
epidural mass, encasing epidural mass, focal
paraspinal mass, and other spinal metastasis
(Table 1). MR imaging findings suggestive of
acute osteoporotic compression fracture were as
follows: low-signal-intensity band on T1- and
T2-weighted images, spared normal bone marrow
signal intensity of the vertebral body, retropulsion
of a posterior bone fragment, and multiple com-
pression fractures. Multivariate logistic analysis
was performed for the findings of low-signal-in-
tensity band, spared normal bone marrow signal
intensity, retropulsion, other spinal metastasis,
convex posterior border of the vertebral body,
and focal paraspinal mass. This analysis showed
that the findings of low-signal-intensity band,
spared normal bone marrow signal intensity, ret-
ropulsion, and other spinal metastasis added pre-
dictive information; however, convex posterior
border of the vertebral body and focal paraspinal
mass did not add predictive information (Table 2).
 RG f Volume 23 ● Number 1 Jung et al 183

RadioGraphics
Table 1
MR Imaging Findings of Metastatic and Acute Osteoporotic Compression Fractures

Percentage of Fractures Results of Multiple

with Finding Logistic Regression
P Value Analysis
Acute from
MR Imaging Finding Metastatic Osteoporotic ␹2 Test P Value Risk Ratio
Convex posterior border of the
vertebral body 74 (20/27) 20 (11/55) ⬍.001 .2818 ...
Retropulsion 11 (3/27) 60 (33/55) ⬍.001 .1040 ...
Compression of all columns 19 (5/27) 18 (10/55) .97 .4124 ...
Spared normal bone marrow
signal intensity 19 (5/27) 85 (47/55) ⬍.001 .0124 0.0222
Low-signal-intensity band 44 (12/27) 93 (51/55) ⬍.001 .0016 86.4071
Abnormal signal intensity of
the pedicle 85 (23/27) 51 (28/55) ⬍.005 .6257 ...
Abnormal signal intensity of
the posterior element 59 (16/27) 24 (13/55) ⬍.005 .8118 ...
Epidural mass 74 (20/27) 25 (14/55) ⬍.001 .2377 ...
Encasing epidural mass 26 (7/27) 2 (1/55) ⬍.005 .0562 36.6961
Paraspinal mass 89 (24/27) 78 (43/55) .24 .8323 ...
Focal paraspinal mass 41 (11/27) 7 (4/55) ⬍.001 .1045 ...
Multiple compression fractures 33 (9/27) 58 (32/55) ⬍.05 .0064 0.0130
Other spinal metastasis 63 (17/27) 5 (3/55) ⬍.001 .0196 0.0408
Note.—Numbers in parentheses are the raw data.

Table 2
Accuracy of MR Imaging Findings in Differentiation of Acute Osteoporotic and Metastatic
Compression Fractures

Results of Multiple
Logistic Regression
Analysis
Sensitivity Specificity Accuracy
MR Imaging Finding P Value Risk Ratio (%) (%) (%)
Low-signal-intensity band* .0004 26.2862 93 56 80
Spared normal bone mar-
row signal intensity* .0202 0.1006 85 81 84
Retropulsion* .0893 ... 60 89 70
Other spinal metastasis† .0207 0.0964 63 95 84
Convex posterior border of
the vertebral body† .2666 ... 74 80 78
Focal paraspinal mass† .1031 ... 41 93 75
*Finding suggestive of acute osteoporotic compression fracture.
†Finding suggestive of metastatic compression fracture.
 184 January-February 2003
RadioGraphics
Figure 3. Unusual acute osteoporotic compression
fracture with a convex posterior cortex of the vertebral
body in a 77-year-old woman. Sagittal turbo spin-echo
T2-weighted MR image (3,200/99, echo train length of
11) shows a convex posterior cortex (arrows) of the L1
vertebral body.
MR Imaging Findings Suggestive
of Metastatic Compression Fractures
Convex Posterior Bor-
der of the Vertebral Body
A convex posterior border of the vertebral body
was more frequent in metastatic compression
fractures than acute osteoporotic compression
fractures (74% of metastatic fractures [Fig 1] vs
20% of acute osteoporotic fractures [Fig 3], P ⬍
.001). These results are consistent with those of
previous reports (6,7).
Abnormal Signal Intensity
of the Pedicle or Posterior Element
A higher frequency of abnormal signal intensity of
the pedicle (85% of metastatic fractures [Fig 1] vs
51% of acute osteoporotic fractures [Fig 4], P ⬍
.005) or posterior element (59% of metastatic
fractures vs 24% of acute osteoporotic fractures,
P ⬍ .005) was observed in metastatic compres-
sion fractures, which is consistent with results of
previous reports (4,6,8). In most malignant com-
pression fractures, tumoral involvement of the
bone marrow of the vertebral body has already
spread to the pedicles and neural arch before col-
lapse, whereas the reactive bone marrow changes
usually spare the pedicles in osteoporotic com-
pression fractures (9). In a previous study (1),
RG f Volume 23 ● Number 1
Figure 4. Unusual acute osteoporotic compression
fracture with abnormal signal intensity of the pedicle
and posterior element in an 89-year-old man. Axial
fat-suppressed contrast-enhanced T1-weighted MR
image (600/15) shows abnormal signal intensity of the
right pedicle extending to the posterior element (ar-
rows). There is a diffuse thin paraspinal mass.
none of 13 acute nontraumatic benign compres-
sion fractures showed abnormal signal intensity in
the pedicle. However, in our study acute osteopo-
rotic compression fractures had abnormal signal
intensity at the pedicle and posterior element in
51% and 24% of cases, respectively.
About one-half of acute osteoporotic compres-
sion fractures in our study showed abnormal sig-
nal intensity of the pedicle, which was a higher
prevalence than in a previous study, in which the
prevalence was 6% (6). The high prevalence of
pedicle involvement in our study could be related
to the increased conspicuity at contrast-enhanced
T1-weighted imaging with fat suppression. In
a study of fat-suppressed contrast-enhanced
T1-weighted imaging by Shih et al (4), 29% of
benign compression fractures (six of 21) showed
abnormal signal intensity of the pedicle. The
somewhat lower prevalence of abnormal signal
intensity of the pedicle in this prior report (4)
could be because they included chronic as well as
acute fractures, unlike our study, which included
only acute compression fractures.
Epidural Mass
As in a previous study (6), an epidural soft-tissue
mass was suggestive of malignant vertebral col-
lapse (74% of metastatic fractures [Fig 1] vs 25%
of acute osteoporotic fractures [Fig 5], P ⬍ .001),
particularly when it was an encasing epidural
mass (26% of metastatic fractures vs 2% of acute
osteoporotic fractures, P ⬍ .005).
 RG f Volume 23 ● Number 1
RadioGraphics
Figure 5. Unusual acute osteoporotic compres-
sion fracture with an epidural mass in a 58-year-old
man. Axial T1-weighted MR image (608/15) shows
an anterior epidural mass (arrows).
Focal Paraspinal Mass
A paraspinal mass was not helpful in differentia-
tion of the cause of vertebral collapse, a result
consistent with that of a previous report by Rupp
et al (12). However, a focal paraspinal mass was
significantly more frequent in metastatic com-
pression fractures (41% of metastatic fractures
[Fig 1] vs 7% of acute osteoporotic fractures, P ⬍
.001), whereas a diffuse paraspinal mass was not.
Other Spinal Metastasis
Signal intensity abnormalities in the marrow of
vertebrae other than the collapsed vertebrae were
more frequently seen in metastatic compression
fractures than acute osteoporotic compression
fractures (63% of metastatic fractures [Fig 1] vs
5% of acute osteoporotic fractures, P ⬍ .001) and
probably indicated other spinal metastases. These
other signal intensity abnormalities of bone mar-
row are most commonly due to other sites of
metastatic disease in patients with metastatic
compression fractures.
MR Imaging Findings
Suggestive of Acute Osteo-
porotic Compression Fractures
Low-Signal-Intensity Band
Bandlike low signal intensity on T1- and T2-
weighted images was more common in acute os-
teoporotic compression fractures than metastatic
compression fractures (93% of acute osteoporotic
fractures [Fig 2] vs 44% of metastatic fractures
[Fig 6], P ⬍ .001).
Jung et al 185
Figure 6. Unusual metastatic compression fracture
with a hypointense band in an 85-year-old man. Sagit-
tal fast spin-echo T2-weighted MR image (3,000/96,
echo train length of eight) shows a hypointense band
(arrows) in the collapsed vertebral body of L2.
Spared Normal Bone
Marrow Signal Intensity
Spared normal bone marrow signal intensity of
the vertebral body was highly suggestive of acute
osteoporotic compression fractures (85% of acute
osteoporotic fractures [Fig 2] vs 19% of meta-
static fractures, P ⬍ .001). In our study, 81% of
metastatic compression fractures had complete
replacement of the normal bone marrow of the
vertebral body, which is consistent with the re-
sults of previous reports (1–3,9). Most vertebral
metastases do not result in compression fractures
until the entire body is infiltrated by tumor, caus-
ing structural bone weakening from destruction of
trabeculae, the cortex, or both (1). Conversely,
the bone softening caused by osteoporosis is
mostly due to loss of bone substance, and the
bone marrow of the vertebral body remains rela-
tively intact (1). In a previous study (1), no be-
nign nontraumatic fractures showed complete
replacement of the normal bone marrow of the
vertebral body. However, in our study 15% of
acute osteoporotic compression fractures had
complete replacement with abnormal signal in-
tensity, which is consistent with the results of pre-
vious reports (4,6). Spread of a fracture-induced
reactive process to the entire vertebra may ac-
count for the pattern of diffuse low signal inten-
sity detected in 15% of the osteoporotic vertebral
collapses.
 186 January-February 2003
RadioGraphics Table 3
Signal Intensity Patterns of Compression Fractures at MR Imaging
Image Type Signal Intensity Pattern
T1-weighted Hypointense to isointense
T2-weighted Hyperintense
Isointense
Hypointense
Fat-suppressed contrast- Homogeneous enhancement
enhanced T1-weighted Heterogeneous enhancement
Note.—Numbers in parentheses are the raw data.
Retropulsion of a
Posterior Bone Fragment
Retropulsion of a posterior bone fragment was
more frequent in osteoporotic compression frac-
tures than metastatic compression fractures (60%
of acute osteoporotic fractures [Fig 2] vs 11% of
metastatic fractures, P ⬍ .001). In a prior study
(6), no malignant compression fractures showed
retropulsion of a posterior bone fragment. How-
ever, in our study 11% of metastatic compression
fractures showed retropulsion on T1- and T2-
weighted images due to compressed bone. It is
possible that some or all of the cases of metastatic
disease with retropulsion of bone fragments were
due to preexisting compression fractures that
were secondarily involved by metastatic disease.
It is also possible that metastatic disease can occa-
sionally be associated with retropulsion of bone
fragments.
Multiple Compression Fractures
In a prior study (12), the finding of multiple com-
pression fractures was not useful in differentiating
osteoporotic from metastatic compression frac-
tures. However, in our study multiple compres-
sion fractures were more frequently observed in
osteoporotic compression fractures (58% of acute
osteoporotic fractures [Fig 2] vs 33% of meta-
static fractures, P ⬍ .05), although about one-
third of metastatic compression fractures were
multiple. This discrepancy could be because we
included only metastatic compression fractures
and excluded multiple myeloma, which often
manifests as multiple compression fractures. Mul-
tiple myeloma was included in the prior study
(12).
RG f Volume 23 ● Number 1
Percentage of Fractures with
Finding
P Value
Acute from ␹2
Metastatic Osteoporotic Test
100 (27/27) 98 (54/55) ⬎.05
33 (9/27) 20 (11/55) ⬎.05
30 (8/27) 40 (22/55) ⬎.05
37 (10/27) 40 (22/55) ⬎.05
4 (1/27) 7 (4/54) ⬎.05
96 (26/27) 93 (50/54) ⬎.05
Patterns of Signal
Intensity and Enhancement
High or inhomogeneous signal intensity of the
compressed vertebral body on T2-weighted im-
ages and on contrast-enhanced MR images has
been reported to be suggestive of malignancy on
conventional spin-echo images (6). However, in
our study the signal intensity on fast spin-echo
T2-weighted images played little role in distin-
guishing between acute benign osteoporotic and
metastatic compression fractures: Eleven benign
fractures versus nine malignant fractures were
hyperintense; 22 benign fractures versus eight
malignant fractures were isointense; and 22 be-
nign fractures versus 10 malignant fractures were
hypointense (P ⫽ .114) (Table 3). This result is
in contrast to those of previous reports of conven-
tional spin-echo or gradient-echo T2-weighted
imaging (1,6,8,9). This difference could be re-
lated to the relatively high signal intensity of fatty
marrow on fast spin-echo T2-weighted images in
our study. Signal intensity less than or equal to
that of skeletal muscle was considered hypoin-
tense. Signal intensity greater than that of skeletal
muscle but less than that of fat was considered
intermediate. Signal intensity equal to or greater
than that of fat was considered hyperintense. In
our study, 98% of osteoporotic compression frac-
tures (54 of 55) and all cases of metastatic com-
pression fractures showed hypointense to isoin-
tense signal intensity within the vertebral body on
T1-weighted images, as in previous reports (10 –
12).
In a recent study of contrast-enhanced T1-
weighted imaging with fat suppression (8),
marked and heterogeneous enhancement was sig-
nificantly more common in metastatic compres-
 RG f Volume 23 ● Number 1
RadioGraphics sion fractures. However, in our study all cases of
metastatic compression fractures demonstrated
intense enhancement on fat-suppressed gadolin-
ium-enhanced T1-weighted images (heteroge-
neous pattern, n ⫽ 26; homogeneous pattern, n ⫽
1) and all cases of acute osteoporotic compression
fractures also showed intense enhancement (het-
erogeneous pattern, n ⫽ 50; homogeneous pat-
tern, n ⫽ 4). Therefore, signal intensity on fat-
suppressed contrast-enhanced T1-weighted im-
ages was not useful in differentiation of acute
osteoporotic from malignant compression frac-
tures, which is consistent with results of previous
studies (4,9). The discrepancy between studies
may be because previous reports included acute
as well as chronic benign compression fractures.
Most centers have replaced conventional T2-
weighted spin-echo imaging with T2-weighted
fast spin-echo imaging. To our knowledge, no
previous reports have evaluated fast spin-echo
T2-weighted images for differentiation of meta-
static versus acute osteoporotic compression frac-
tures.
Limitations of Our Study
Interpretation of MR images was performed by
one experienced musculoskeletal radiologist.
Thus, interobserver variability and accuracy for
less experienced radiologists were not assessed.
All compression fractures were not confirmed
with biopsy. The lack of pathologic proof could
be a more serious limitation in an analysis of indi-
vidual vertebral segments rather than individual
patients. Sample sizes in this study were small.
The reviewer knew that all cases of compression
fractures were metastatic or osteoporotic. This
may have increased the sensitivity of MR imaging
for diagnosis of metastatic compression fractures.
The study did not include any cases of multiple
myeloma, which would likely be more problem-
atic for MR imaging diagnosis than metastasis.
The lack of usefulness of T2-weighted images in
our study might have been due to lack of fat sup-
pression.
Conclusions
Some MR imaging findings are useful for differ-
entiation of metastatic from acute osteoporotic
compression fractures of the spine. A convex pos-
terior border of the vertebral body, abnormal sig-
nal intensity of the pedicle or posterior element,
an epidural mass, a focal paraspinal mass, and
other spinal metastases are suggestive of meta-
static compression fractures. A low-signal-inten-
sity band on T1- and T2-weighted images, spared
Jung et al 187
normal bone marrow signal intensity of the verte-
bral body, retropulsion of a posterior bone frag-
ment, and multiple compression fractures are
suggestive of acute osteoporotic compression
fractures. A more formal prospective study with a
larger number of patients is needed to confirm
these findings.
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