Findings on routine MRI sequences are suggested as a method to differentiate osteoporotic from neoplastic vertebral fractures.

Grade of Recommendation: B

In a retrospective observational study, Abdel-Wanis et al1 studied the sensitivity, specificity, and validity of several MRI features in differentiating vertebral compression fractures that are caused by malignancy, osteoporosis, and infections. The authors concluded that “Combination of several MRI features can provide clues to differentiate between malignant, osteoporotic, and infective vertebral compression fractures.” This paper provides Level III evidence that MRI features differentiate between malignant, osteoporotic, and infectious fractures.

In a retrospective comparative study, Baur et al2 assessed the event, location, and form of the fluid sign in acute osteoporotic and neoplastic vertebral compression fractures at magnetic resonance (MR) imaging. The authors describe the fluid sign as signal intensity similar to cerebrospinal fluid (CSF) immediately beneath a fractured endplate. The authors concluded that “The fluid sign is featured in acute vertebral compression fractures that show bone marrow edema. It can be an additional sign of osteoporosis and rarely occurs in metastatic fractures.” This paper provides Level III evidence that the fluid sign on MRI is a feature seen with osteoporotic fractures and rare in metastatic fractures.

In a retrospective observational study, Cuénod et al3 compared the abnormality patterns found in acute osteoporotic and malignant vertebral collapses using unenhanced and gadolinium-enhanced non-fat-suppressed MR images. The authors concluded that “Gadolinium-enhanced and unenhanced MR images are useful in the differentiation of vertebral collapses.” This paper provides Level III evidence that many MR Imaging findings are useful in differentiating osteoporotic from malignant compression fractures.

In a retrospective observational study, Hamimi et al4 evaluated the different MRI signs that would help in differentiating between benign and malignant vertebral fractures. The authors concluded that “Several signs are found to favor osteoporotic or malignant vertebral fractures. Chemical shift and DWI are strong allies to morphological signs in differentiating between both entities. Depending on a group of signs rather than one sign alone would increase the diagnostic accuracy.” This paper provides Level III evidence that several signs are found to favor osteoporotic or malignant vertebral fractures. Chemical shift and DWI are good adjuncts to morphological findings to differentiate between benign and malignant vertebral fractures.

In a retrospective observational study, He et al5 investigated the differential diagnostic value of F-FDG PET/CT for benign and malignant vertebral compression fractures, where the diagnostic accuracy was compared to MRI. The authors concluded that “Significant MRI findings such as convex posterior cortex, epidural mass formation, and pedicle enhancement are highly suggestive of malignancy. 18F-FDG PET/CT reliably differentiated the fractures of malignant from benign based on both SUVmax and 18F-FDG uptake pattern. In a situation where MRI findings are not diagnostic, 18F-FDG PET/CT provides additional information as it has high sensitivity and is semiquantitative.” This paper provides Level III evidence that certain MRI findings are highly suggestive of malignancy; for equivocal MRI findings, using PET/CT imaging will increase the sensitivity for determining malignancy.

In a retrospective observational study, Fu et al6 aimed to ascertain which conventional MRI parameters are helpful for the early differentiation between benign and malignant vertebral fractures. The authors concluded that “Certain MRI characteristics allow early differentiation of benign and malignant vertebral fractures.” This paper provides Level IV evidence that several MRI findings are useful for early differentiation between osteoporotic and malignant vertebral fractures and the presence of a soft tissue mass was most predictive of malignancy.

In a retrospective comparative study, Lee et al7 evaluated the diagnostic role of the contrast-enhanced MRI (CE-MRI) in differentiating between malignant and benign vertebral compression fractures, focusing more so on the internal transparent trabecular bone on CE-MRI (the ‘‘see- through sign’’). The authors concluded that “The see-through sign on CE-MRI is featured in acute benign VCFs, and it can be a useful finding to differentiate between benign and malignant VCFs.” This paper provides Level III evidence that the presence of the see through sign on CE-MRI is significantly more common in benign VCFs than malignant VCFs.

In a retrospective comparative study, Moulopoulos et al8 detailed a constellation of MR criteria that can be used in the analysis of the etiology of a compression fracture. The authors showed that MR signal intensity of an involved vertebra is the strongest criterion in predicting benign versus malignant nature and multiple regression analysis showed greatest accuracy of 94% when using criteria of signal intensity, shape, location and focal convexity. The work group downgraded this potential Level II paper due to inconsistent use of a gold standard, biopsy, or follow-up MR imaging to prove the results were accurate. This paper provides Level III evidence that adding additional criteria has the potential to increase that accuracy to 94%.

In a retrospective case series study, Tan et al9 aimed to distinguish MRI features of benign and malignant vertebral fractures and differentiate between osteoporotic, traumatic, and infectious causes. The authors concluded that “MRI can be used to accurately differentiate between benign and malignant causes of vertebral collapse.” The work group downgraded this potential Level III paper due to nonconsecutive patients, small sample size, nonmasked reviewers, no consistently applied gold standard, and poor reference standard. This paper provides Level IV evidence that certain MRI findings can distinguish benign versus neoplastic vertebral fractures.

In a retrospective comparative study, Tokuda et al10 aimed to establish whether bone single-photon emission tomography (SPECT) can be used as a substitute for magnetic resonance (MR) imaging for differentiating between malignant and benign vertebral compression fractures. The authors concluded that “Bone SPECT may be comparable with MR imaging for differentiating malignant from benign VCFs, especially, in the case of VCFs with a complete replacement of the normal fatty marrow.” The work group downgraded this potential Level III paper due to no consistent application of the gold standard. This paper provides Level IV evidence that in cases of VCF with partial replacement of the normal fatty bone marrow, MRI is more accurate than SPECT imaging in distinguishing a benign vs malignant etiology; this differentiation is not possible in VCFs with complete replacement of the normal fatty marrow.

In a retrospective comparative study, Shih et al11 aimed to characterize the MR pattern of compression fractures in benign and malignant processes. The authors concluded that “In conclusion, the differential diagnosis of a solitary vertebral collapse with either a benign or malignant cause can be easily performed by MRI.” This paper provides Level III evidence that morphologic appearance of the fracture on MR imaging is useful to distinguish benign vs. malignant vertebral fracture.

n a retrospective comparative study, Pongpornsup et al12 assessed the validity, sensitivity, and specificity of magnetic resonance imaging features in differentiating between malignant and benign compression fracture of the spine. The authors concluded that “Certain MR imaging characteristics can reliably distinguish malignant from benign compression fracture of the spine. Combination of several MRI features strongly affirmed the diagnosis of malignant compression fracture, especially in a patient where tissue biopsy is not justified.” The work group downgraded this potential Level III paper due to nonconsecutive patients and no consistent or universally applied gold standard. This paper provides Level IV evidence that certain MRI features (involvement of pedicle or posterior element) were highly sensitive and specific for differentiation between malignant and osteoporotic compression fractures.

In a retrospective observational study, Ishiyama et al13 aimed to assess the prevalence and properties of pedicle-involvement change on MRI in painful osteoporotic compression fractures and to decide whether the findings are accurately specific for malignancy. The authors concluded that “Pedicle involvement was seen frequently in patients with osteoporotic compression fractures and was not specific for malignancy in our study group.” This paper provides Level IV evidence that pedicular involvement of the fracture is not necessarily specific for neoplastic vertebral fracture.

In a retrospective comparative study, Takigawa et al14 studied the MRI features that could differentiate benign and malignant vertebral fractures. The authors concluded that “Although each MRI feature had a different meaning with a variable differentiation power, combining them led to an accurate diagnosis. This study identified the most relevant MRI features that would be helpful in discriminating benign from malignant vertebral fractures.” The work group downgraded this potential Level III paper due to nonconsecutive patients and nonmasked reviewers. This paper provides Level IV evidence that with the exception of multiple myeloma, when trying to distinguish a malignant vs benign etiology in patients with VCF, using these MRI characteristics allowed a predictive value of 97.3%: posterior wall diffuse protrusion, pedicle and posterior involvement, and the benign features of a band pattern.

In a retrospective observational study, Yuh et al15 aimed to characterize and assess the MR imaging appearance of compression fractures due to benign or malignant processes to define the criteria that would be useful in differentiating these two entities. The authors concluded that “When criteria based on complete loss or preservation of bone marrow were applied for cases with incomplete loss, differentiation between benign and malignant compression fractures would be achieved with 94% accuracy.” This paper provides Level IV evidence that preservation of normal-signal intensity bone marrow on MRI is helpful to identify benign and malignant vertebral compression fractures.

References

1. Abdel-Wanis ME, Solyman MT, Hasan NM. Sensitivity, specificity and accuracy of magnetic resonance imaging for differentiating vertebral compression fractures caused by malignancy, osteoporosis, and infections. J Orthop Surg (Hong Kong). 2011;19(2):145-150. doi:10.1177/230949901101900203.
2. Baur A, Stabler A, Arbogast S, Duerr HR, Bartl R, Reiser M. Acute osteoporotic and neoplastic vertebral compression fractures: fluid sign at MR imaging. Radiology. 2002; 25(3):730-735. doi: 10.1148/radiol.2253011413.
3. Cuénod CA, Laredo JD, Chevret S, et al. Acute vertebral collapse due to osteoporosis or malignancy: appearance on unenhanced and gadolinium-enhanced MR images. Radiology. 1996;199(2):541-549. doi:10.1148/radiology.199.2.8668809
4. Hamimi A, Kassab F, Kazkaz G. Osteoporotic or malignant vertebral fracture? This is the question. What can we do about it? Egyptian Journal of Radiology and Nuclear Medicine. 2015;46(1):97-103. FILE-ALT
5. He X, Zhao L, Guo X, et al. Differential diagnostic value of 18F-FDG PET/CT for benign and malignant vertebral compression fractures: comparison with magnetic resonance imaging. Cancer Manag Res. 2018;10:2105-2115. Published 2018 Jul 18. doi:10.2147/CMAR.S168374.
6. Fu TS, Chen LH, Liao JC, Lai PL, Niu CC, Chen WJ. Magnetic resonance imaging characteristics of benign and malignant vertebral fractures. Chang Gung Med J. 2004;27(11):808-815.
7. Lee E, Lee JW, Lee J, et al. Acute benign vertebral compression fractures: "see-through sign" on contrast-enhanced MR images. Eur Spine J. 2016;25(11):3470-3477. doi:10.1007/s00586-015-4312-4.
8. Moulopoulos LA, Yoshimitsu K, Johnston DA, Leeds NE, Libshitz HI. MR prediction of benign and malignant vertebral compression fractures. J Magn Reson Imaging. 1996;6(4):667-674. doi:10.1002/jmri.1880060416.
9. Tan DY, Tsou IY, Chee TS. Differentiation of malignant vertebral collapse from osteoporotic and other benign causes using magnetic resonance imaging. Ann Acad Med Singap. 2002;31(1):8-14.
10. Tokuda O, Harada Y, Ueda T, Ohishi Y, Matsunaga N. Malignant versus benign vertebral compression fractures: can we use bone SPECT as a substitute for MR imaging?. Nucl Med Commun. 2011;32(3):192-198. doi:10.1097/MNM.0b013e3283425665.
11. Shih TT, Huang KM, Li YW. Solitary vertebral collapse: distinction between benign and malignant causes using MR patterns. J Magn Reson Imaging. 1999;9:635–42. doi: 10.1097/MNM.0b013e3283425665.
12. Pongpornsup S, Wajanawichakorn P, Danchaivijitr N. Benign versus malignant compression fracture: a diagnostic accuracy of magnetic resonance imaging. J Med Assoc Thai. 2009;92(1):64-72.
13. Ishiyama M, Fuwa S, Numaguchi Y, Kobayashi N, Saida Y. Pedicle involvement on MR imaging is common in osteoporotic compression fractures. AJNR Am J Neuroradiol. 2010;31(4):668-673. doi:10.3174/ajnr.A1905.
14. Takigawa T, Tanaka M, Sugimoto Y, Tetsunaga T, Nishida K, Ozaki T. Discrimination between Malignant and Benign Vertebral Fractures Using Magnetic Resonance Imaging. Asian Spine J. 2017;11(3):478-483. doi:10.4184/asj.2017.11.3.478. FILE-ALT
15. Yuh WT, Zachar CK, Barloon TJ, Sato Y, Sickels WJ, Hawes DR. Vertebral compression fractures: distinction between benign and malignant causes with MR imaging. Radiology. 1989;172(1):215-218. doi:10.1148/radiology.172.1.2740506.

Specific MRI sequences are suggested to differentiate osteoporotic from neoplastic vertebral fractures.

Grade of Recommendation: B

In a prospective comparative study, Schmeel et al1 assessed the diagnostic performance of T2*-weighted magnetic resonance imaging, when used to differentiate between acute benign and neoplastic vertebral compression fractures. The authors concluded that “Quantitative assessment of vertebral bone marrow T2* relaxation times provides good diagnostic accuracy for the differentiation of acute benign and malignant VCFs.” The work group downgraded this potential Level I paper due to low sample size. This paper provides Level II evidence that T2 MRI parameters provide good diagnostic accuracy to distinguish between malignant vs benign compression fractures.

In a prospective observational study, Bhugaloo et al2 aimed to characterize and differentiate benign and malignant vertebral compression fractures compared to conventional T1 WI, T2 WI, and fat suppressed contrast enhanced T1 WI in the Malaysian population by assessing the specificity and sensitivity of diffusion weighted MR imaging (DWI). The authors concluded that “When the findings on routine MR sequences are not completely conclusive for the diagnosis of acute benign or malignant vertebral body compression fracture, then the use of both contrast enhancement and diffusion weighted MR sequence may be helpful. We found that absence of contrast enhancement has a high NPV (90%) while SSFP DWI has both a high PPV (90%) and high NPV (90%) in detecting malignant vertebral compression fractures.” This paper provides Level III evidence that in MRI of NVF, absence of contrast enhancement has a high negative predictive value for malignant VBCF and SSFP DWI (steady state free precession diffusion-weighted) has both a high positive predictive value and a high negative predictive value in detecting malignant VCF.

In a retrospective observational study, Eito et al3 compared vertebrae that display neoplastic compression fractures with normal vertebrae using opposed-phase (OP) and in-phase (IP) gradient-echo (GRE) imaging. The authors concluded that “OP and IP T1-W GRE MRI of vertebral SI abnormalities can help predict the nature of compression fractures.” This paper provides Level III evidence that the use of opposed phase and in phase gradient-echo imaging is useful in distinguishing osteoporotic and neoplastic fractures.

In a prospective comparative study, Ragab et al4 sought to determine the cut-off value of the signal intensity drop for chemical shift magnetic resonance imaging with applicable sensitivity and specificity to differentiate between neoplastic and osteoporotic wedging of the spine. The authors concluded that “A chemical shift MRI is useful in order to differentiate patients with vertebral collapse due to underlying osteoporosis or neoplastic process.” The work group downgraded this potential Level II paper due to small sample size and nonmasked reviewers. This paper provides Level III evidence that a chemical shift MRI (using a cut off value of 35%) is both sensitive and specific for neoplastic VCF.

In a retrospective comparative study, Ogura et al5 evaluated the value of in-phase/opposed phase and short TI inversion recovery (STIR) magnetic resonance imaging (MRI) of bone marrow, when it comes to differentiating between benign vertebral compression fractures and malignant vertebral compression fractures. The authors concluded “In cases of acute compression fracture, malignant bone marrow showed SIR(STIR) values less than 2.0 and SIR (in/opposed) greater than 1.0. In contrast, benign bone marrow showed SIR (STIR) values greater than 2.5. For chronic compression fracture, malignant bone marrow showed SIR (in/opposed) greater than 1.0. Bone marrow was benign in all cases with SIR (in/opposed) less than 1.0.” The work group downgraded this potential Level III paper due to nonconsecutive patients, small sample size, no consistent or universal application of a gold standard, and nonmasked reviewers. This paper provides Level IV evidence that SIR and STIR imaging allows differentiation between benign and malignant compression fractures.

In a retrospective comparative study, Yamamoto et al6 studied the value of sagittal T1-weighted MRI findings for differentiating metastatic and osteoporotic vertebral fractures. The authors concluded that “Characteristic findings with sagittal T1-weighted MRI were useful in the differential diagnosis of metastatic and osteoporotic vertebral fractures.” The work group downgraded this potential Level III paper due to nonconsecutive patients. This paper provides Level IV evidence that sagittal T-1 images on MRI are useful to differentiate osteoporotic and metastatic vertebral fractures.

References

1. Schmeel FC, Luetkens JA, Feißt A, et al. Quantitative evaluation of T2* relaxation times for the differentiation of acute benign and malignant vertebral body fractures. Eur J Radiol. 2018;108:59-65. doi:10.1016/j.ejrad.2018.09.021.
2. Bhugaloo A, Abdullah B, Siow Y, Ng Kh. Diffusion weighted MR imaging in acute vertebral compression fractures: differentiation between malignant and benign causes. Biomed Imaging Interv J. 2006;2(2):e12. doi:10.2349/biij.2.2.e12. FILE-ALT
3. Eito K, Waka S, Naoko N, Makoto A, Atsuko H. Vertebral neoplastic compression fractures: assessment by dual-phase chemical shift imaging. J Magn Reson Imaging. 2004;20(6):1020-1024. doi:10.1002/jmri.20213.
4. Ragab Y, Emad Y, Gheita T, et al. Differentiation of osteoporotic and neoplastic vertebral fractures by chemical shift {in-phase and out-of phase} MR imaging. Eur J Radiol. 2009;72(1):125-133. doi:10.1016/j.ejrad.2008.06.019.
5. Ogura A, Hayakawa K, Maeda F, et al. Differential diagnosis of vertebral compression fracture using in-phase/opposed-phase and short TI inversion recovery imaging. Acta Radiol. 2012;53(4):450-455. doi:10.1258/ar.2012.110524.
6. Yamamoto Y, Iwata E, Shigematsu H, et al. Differential diagnosis between metastatic and osteoporotic vertebral fractures using sagittal T1-weighted magnetic resonance imaging. J Orthop Sci. 2020;25(5):763-769. doi:10.1016/j.jos.2019.10.004.

Diffusion weighted imaging (DWI) is suggested as a MR sequence to distinguish osteoporotic from neoplastic vertebral fractures.

Grade of Recommendation: B

In a prospective observational study, Geneidi et al1 assessed the usefulness of diffusion-weighted imaging (DWI) for differentiating between malignant and benign bone tumors. The authors concluded that “In conclusion we prove high specificity and sensitivity of DWI in discrimination between benign and malignant bone tumors with significant cut-off value, making it a non-invasive tool in diagnosis of bone marrow metastasis and differentiating it from other benign lesions.” This paper provides Level II evidence that MRI with diffusion-weighted imaging has a diagnostic value in the

discrimination between benign and malignant lesions in the vertebral body.

In a retrospective comparative study, Pozzi et al2 investigated the value of magnetic resonance imaging (MRI) with spin-echo echo-planar diffusion- weighted imaging (SE-EPI-DWI) when it comes to differentiating between vertebral osteoporotic fractures and pathological neoplastic fractures. The authors concluded that “DWI provides reliable information to support MRI diagnosis of neoplastic versus osteoporotic fractures. ADC value appears as a useful adjunctive parameter.” The work group downgraded this potential Level I paper due to the patients not being consecutively assigned. This paper provides Level II evidence that DWI provides reliable data to distinguish between osteoporotic and malignant fractures.

In a prospective observational study, Balliu et al3 evaluated the value of apparent diffusion coefficient (ADC), which is attained through diffusion weighted (DWI) MR, when it comes to differentiating between benign and malignant bone marrow lesions. The authors concluded that “ADC values are a useful complementary tool to characterize bone marrow lesions, in order to distinguish acute benign fractures from malignant or infectious bone lesions. However, ADC values are not valuable in order to differentiate malignancy from infection.” This paper provides Level III evidence that measuring ADC values helps distinguish between benign and malignant compression fractures, but not between malignant fractures and infection.

In a prospective comparative study, Baur et al4 studied the impact of increasing diffusion weighting of a diffusion-weighted steady-state free precession (SSFP) sequence to differentiate between acute benign and neoplastic vertebral compression fractures. The authors concluded “Increasing diffusion weighting can reduce false-positive hyperintense osteoporotic fractures or make hypointensity more obvious in cases of osteoporotic fractures.” This paper provides Level III evidence that DWI using increased diffusion weighting reduces false positive signal of osteoporotic VCFs.

In a prospective comparative study, Baur et al5 assessed the value of diffusion-weighted magnetic resonance imaging of bone marrow, when used to differentiate between benign and pathologic vertebral compression fractures. The authors concluded that “Diffusion-weighted MR imaging provided excellent distinction between pathologic and benign vertebral compression fractures.” This paper provides Level III evidence that diffusion-weighted MRI is able to differentiate between pathologic and benign vertebral compression fractures.

In a prospective observational study, Biffar et al6 studied spin-lattice (T1) and spin-spin (T2) relaxation timings as well as apparent diffusion coefficients (ADCs) of the physical properties (fat and water components) in the vertebral bone marrow (vBM) of patients who had benign and malignant vertebral lesions. The authors concluded that “All parameters exhibit significant differences between normal-appearing vBM and the lesions. However, only the ADCs determined with the DW-ssTSE differed significantly between osteoporotic fractures and malignant lesions potentially allowing for a differential diagnosis of these two entities.” This paper provides Level III evidence that only the ADCs determined with DW-ssTSE differed significantly between osteoporotic and malignant lesions potentially allowing for a differential diagnosis between these two entities.

In a prospective observational study, Bhugaloo et al7 aimed to characterize and differentiate benign and malignant vertebral compression fractures compared to conventional T1 WI, T2 WI and fat suppressed contrast enhanced T1 WI in the Malaysian population by assessing the specificity and sensitivity of diffusion weighted MR imaging (DWI). The authors concluded that “When the findings on routine MR sequences are not completely conclusive for the diagnosis of acute benign or malignant vertebral body compression fracture, then the use of both contrast enhancement and diffusion weighted MR sequence may be helpful. We found that absence of contrast enhancement has a high NPV (90%) while SSFP DWI has both a high PPV (90%) and high NPV (90%) in detecting malignant vertebral compression fractures.” This paper provides Level III evidence that in MRI of NVF, absence of contrast enhancement has a high negative predictive value for malignant NVF and SSFP DWI (steady state free precession diffusion-weighted) has both a high positive predictive value and a high negative predictive value in detecting malignant VBCF.

In a prospective observational study, Geith et al8 compared the diagnostic value of qualitative and quantitative diffusion-weighted imaging (DWI), and chemical-shift imaging in patients with acute osteoporotic and malignant vertebral compression fractures. The authors concluded that “Qualitative assessment of opposed-phase, DW-EPI, and DW single-shot TSE sequences and quantitative assessment of the DW-EPI sequence were not suitable for distinguishing between benign and malignant vertebral fractures.” This paper provides Level III evidence that DWI-PSIF had the highest accuracy differentiating between benign vs malignant vertebral fractures with a sensitivity of 100%; a specificity of 88.5% and an accuracy of 93.5%.

In a retrospective observational study, Hamimi et al9 evaluated the different MRI signs that would help in differentiating between benign and malignant vertebral fractures. The authors concluded that “Several signs are found to favor osteoporotic or malignant vertebral fractures. Chemical shift and DWI are strong allies to morphological signs in differentiating between both entities. Depending on a group of signs rather than one sign alone would increase the diagnostic accuracy.” This paper provides Level III evidence that several signs are found to favor osteoporotic or malignant vertebral fractures. Chemical shift and DWI are good adjuncts to morphological findings to differentiate between benign and malignant vertebral fractures.

In a prospective comparative study, Maeda et al10 aimed to assess the value of diffusion abnormalities quantitatively in benign and malignant vertebral compression fractures, using line scan diffusion-weighted imaging (DWI). The authors concluded that “Although the quantitative assessment of vertebral diffusion provides additional information concerning compressed vertebrae, the benign and malignant compression fracture apparent diffusion coefficient (ADC) values overlap considerably. Therefore, even a quantitative vertebral diffusion assessment may not always permit a clear distinction between benign and malignant compression fractures.” This paper provides Level III evidence that quantitative assessment of ADC values using diffusion weighted imaging may not reliably distinguish between benign and malignant compression fractures due to an overlap in ADC values.

In a prospective comparative study, Mubarak et al11 assessed the sensitivity, specificity, and validity of diffusion-weighted (DWI) magnetic resonance imaging (MRI) in the diagnosis and differentiation between malignant and benign vertebral compression fractures, in relation to histology findings and clinical follow-up. The authors concluded that “Diffusion weighted magnetic resonance imaging offers a safe, accurate and non invasive modality to differentiate between the benign and malignant vertebral compression fracture.” The work group downgraded this potential Level III paper due to small sample size, nonmasked reviewers, poor reference standard, and lack of a consistently applied gold standard. This paper provides Level IV evidence that diffusion-weighted MRI is 85% accurate in differentiating between benign and malignant vertebral compression fractures.

In a prospective comparative study, Oztekin et al12 investigated the value of single-shot echoplanar imaging sequences (diffusion-weighted imaging (DWI)/SSH-EPI) with low b value in the differentiation between malignant metastatic tumor infiltration of vertebral bone marrow and benign vertebral fracture edema. The authors concluded that “Single-shot echo-planar imaging sequences (DWI/SSH-EPI) with low b value provided excellent distinction between metastatic tumor infiltration and benign vertebral fracture edema. Hyperintense signal intensity on DWI/SSH-EPI was highly specific for the diagnosis of metastatic tumor infiltration of the spine.” This paper provides Level III evidence that diffusion-weighted imaging using single-shot echo-planar imaging is excellent in differentiating between metastatic tumor fractures from benign vertebral fractures.

In a retrospective case control study, Byun et al13 aimed to ascertain if a steady state free precession (SSFP) DW MRI would be useful in differentiating metastases of the sacrum from sacral insufficiency fractures. The authors concluded that “SSFP diffusion-weighted MRI is capable of differentiating benign sacral insufficiency fractures from metastatic tumors of the sacrum.“ This paper provides Level IV evidence that SSFP DWI MRI evaluation of the sacrum can help differentiate benign from malignant fractures.

In a prospective comparative study, Park et al14 studied the value of single shot fast spin echo diffusion-weighted MR imaging (DWSSFSE) in the differentiation between malignant metastatic tumor infiltration of vertebral bone marrow from benign vertebral fracture edema. The authors concluded that “DWSSFSE of the spine may be useful in differentiating metastatic tumor infiltration of vertebral bone marrow from benign fracture edema.” This paper provides Level IV evidence that DWI is highly specific but not sensitive for metastatic tumor.

In a prospective case series study, Zhou et al15 aimed to test the hypothesis, using a diffusion imaging technique, that malignant and benign vertebral lesions can be differentiated on the basis of tissue apparent diffusion coefficient (ADCs). The authors concluded that “quantitative ADC mapping, instead of qualitative diffusion-weighted imaging, can provide valuable information in differentiating benign vertebral fractures from metastatic lesions.” This paper provides Level IV evidence that quantitative ADC mapping is more sensitive than quantitative diffusion imaging technique.

References

1. Geneidi EAS, Ali HI, Dola EF. Role of DWI in characterization of bone tumors. Egypt J Radiol Nuclear Med. 2016;47(3):919-927. Doi: 10.1016/j.ejrnm.2016.06.017
2. Pozzi G, Garcia Parra C, Stradiotti P, Tien TV, Luzzati A, Zerbi A. Diffusion-weighted MR imaging in differentiation between osteoporotic and neoplastic vertebral fractures. Eur Spine J. 2012;21 Suppl 1(Suppl 1):S123-S127. doi:10.1007/s00586-012-2227-x. FILE-ALT
3. Balliu E, Vilanova JC, Peláez I, et al. Diagnostic value of apparent diffusion coefficients to differentiate benign from malignant vertebral bone marrow lesions. Eur J Radiol. 2009;69(3):560-566. doi:10.1016/j.ejrad.2007.11.037.
4. Baur A, Huber A, Ertl-Wagner B, et al. Diagnostic value of increased diffusion weighting of a steady-state free precession sequence for differentiating acute benign osteoporotic fractures from pathologic vertebral compression fractures. AJNR Am J Neuroradiol. 2001;22:366–72. FILE-ALT
5. Baur A, Stabler A, Bruning R, et al. Diffusion-weighted MR imaging of bone marrow: differentiation of benign versus pathologic compression fractures. Radiology. 1998;207:349–56.
6. Biffar A, Baur-Melnyk A, Schmidt GP, Reiser MF, Dietrich O. Multiparameter MRI assessment of normal-appearing and diseased vertebral bone marrow. Eur Radiol. 2010;20(11):2679-2689. doi:10.1007/s00330-010-1833-4.
7. Bhugaloo A, Abdullah B, Siow Y, Ng Kh. Diffusion weighted MR imaging in acute vertebral compression fractures: differentiation between malignant and benign causes. Biomed Imaging Interv J. 2006;2(2):e12. doi:10.2349/biij.2.2.e12.
8. Geith T, Schmidt G, Biffar A, et al. Comparison of qualitative and quantitative evaluation of diffusion-weighted MRI and chemical-shift imaging in the differentiation of benign and malignant vertebral body fractures. AJR Am J Roentgenol. 2012;199(5):1083-1092. doi:10.2214/AJR.11.8010.
9. Hamimi A, Kassab F, Kazkaz G. Osteoporotic or malignant vertebral fracture? This is the question. What can we do about it? Egypt J Radiol Nuclear Med. 2015;46(1):97-103.
10. Maeda M, Sakuma H, Maier SE, et al. Quantitative assessment of diffusion abnormalities in benign and malignant vertebral compression fractures by line scan diffusion-weighted imaging. AJR Am J Roentgenol. 2003;181:1203–9. doi: 10.2214/ajr.181.5.1811203.
11. Mubarak F, Akhtar W. Acute vertebral compression fracture: differentiation of malignant and benign causes by diffusion weighted magnetic resonance imaging. J Pak Med Assoc. 2011;61(6):555-558.
12. Oztekin O, Ozan E, Hilal Adibelli Z, Unal G, Abali Y. SSH-EPI diffusion-weighted MR imaging of the spine with low b values: is it useful in differentiating malignant metastatic tumor infiltration from benign fracture edema? Skeletal Radiol. 2009; 38:651–658. DOI: 10.1007/s00256-009-0668-z
13. Byun WM, Jang HW, Kim SW, Jang SH, Ahn SH, Ahn MW. Diffusion-weighted magnetic resonance imaging of sacral insufficiency fractures: comparison with metastases of the sacrum. Spine (Phila Pa 1976). 2007;32(26):E820-E824. doi:10.1097/BRS.0b013e31815ce70c.
14. Park SW, Lee JH, Ehara S, et al. Single shot fast spin echo diffusion-weighted MR imaging of the spine; Is it useful in differentiating malignant metastatic tumor infiltration from benign fracture edema?. Clin Imaging. 2004;28(2):102-108. doi:10.1016/S0899-7071(03)00247-X.
15. Zhou XJ, Leeds NE, McKinnon GC, Kumar AJ. Characterization of benign and metastatic vertebral compression fractures with quantitative diffusion MR imaging. AJNR Am J Neuroradiol. 2002;23(1):165-170. FILE-ALT

Contrast enhanced perfusion MRI is suggested as a method to differentiate between osteoporotic and neoplastic vertebral compression fractures.

Grade of Recommendation: B

In a retrospective observational study, Arevalo-Perez et al1 evaluated dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in differentiating between pathologic and benign vertebral fractures. The authors concluded that “Our data demonstrate that T1-weighted DCE-MRI has potential to differentiate between pathologic vs. benign, acute vs. chronic, and most important, benign acute vs. pathologic vertebral fractures.” This paper provides Level II evidence that certain perfusion parameters associated with DCE-MRI are able to distinguish benign vs malignant and acute vs non-acute vertebral body fractures.

In a prospective observational study, Geith et al2 assessed quantitative dynamic contrast-enhanced MRI (DCE-MRI) to differentiate between benign vertebral fractures from malignant vertebral fractures based on the tracer kinetic modeling of perfusion. The authors concluded that “In spots of high plasma flow, which can be determined with a deconvolution analysis, the quantitative perfusion parameters of interstitial volume, ECV, and extraction flow are significantly different between acute osteoporotic and malignant vertebral fractures and can aid in the distinction between the two entities.” This paper provides Level III evidence that high plasma flow on perfusion MRI was able to differentiate between acute osteoporotic and malignant vertebral fractures.

References

1. Arevalo-Perez J, Peck KK, Lyo JK, Holodny AI, Lis E, Karimi S. Differentiating benign from malignant vertebral fractures using T1 -weighted dynamic contrast-enhanced MRI. J Magn Reson Imaging. 2015;42(4):1039-1047. doi:10.1002/jmri.24863. FILE-ALT
2. Geith T, Biffar A, Schmidt G, et al. Quantitative analysis of acute benign and malignant vertebral body fractures using dynamic contrast-enhanced MRI. AJR Am J Roentgenol. 2013;200(6):W635-W643. doi:10.2214/AJR.12.9351.

PET scan is suggested to differentiate between osteoporotic and neoplastic vertebral compression fractures.

Grade of Recommendation: B

In a retrospective comparative study, Bredella et al1 analyzed the use of fluorodeoxyglucose positron emission tomography (FDG-PET) in differentiating a benign compression fracture from a malignant compression fracture. The authors concluded that “Fluorodeoxyglucose positron emission tomography is useful in differentiating benign from malignant compression fractures. Therapy with bone marrow-stimulating agents can mimic malignant involvement.” This paper provides Level III evidence that FDG-PET can be helpful in identifying malignant compression fractures.

In a retrospective comparative study, Cho et al2 compared the ability ot MRI findings and PET/ fluorodeoxyglucose positron emission tomography (FDG-PET) in differentiating between malignant and benign vertebral compression fractures. The authors concluded that “When MR imaging findings are equivocal, FDG-PET/CT can be considered as an adjunctive diagnostic method for differentiating malignant from benign VCFs. In comparison with MR imaging, FDG-PET/CT showed slightly higher sensitivity and lower specificity”. This paper provides Level III evidence that FDG-PET/CT is a useful adjunctive diagnostic method for differentiating malignant vs. benign VCF when MRI results are inconclusive or unavailable.

References

1. Bredella MA, Essary B, Torriani M, Ouellette HA, Palmer WE. Use of FDG-PET in differentiating benign from malignant compression fractures. Skeletal Radiology. 2008;37(5):405-413. doi:10.1007/s00256-008-0452-5. FILE-ALT
2. Cho WI, Chang UK. Comparison of MR imaging and FDG-PET/CT in the differential diagnosis of benign and malignant vertebral compression fractures. J Neurosurg Spine. 2011;14(2):177-183. doi:10.3171/2010.10.SPINE10175.

There is insufficient evidence to make a recommendation for or against the use of bone scans to differentiate osteoporotic from neoplastic vertebral compression fractures.

Grade of Recommendation: I

In a prospective cohort study, Thariat et al1 investigated the value of thallium-201 (201TI) scintigraphy for differentiating between benign and malignant recent non-traumatic compression fractures. The authors concluded that “The weak sensitivity does not support the wide use of 201TI bone scintigraphy to distinguish a benign from a malignant recent non traumatic vertebral fracture. However, the high specificity suggests that such evaluation might be proposed prior to vertebral biopsy in some difficult cases.” The work group downgraded this potential Level III paper due to small sample size. This paper provides Level IV evidence that bone scintigraphy has low sensitivity and should not be used as a screening test for malignant VCF, but because of the high specificity bone scintigraphy may have some utility in difficult cases.

In a retrospective comparative study, Tokuda et al2 aimed to establish whether bone single-photon emission tomography (SPECT) can be used as a substitute for magnetic resonance (MR) imaging for differentiating between malignant and benign vertebral compression fractures. The authors concluded that “Bone SPECT may be comparable with MR imaging for differentiating malignant from benign VCFs, especially, in the case of VCFs with a complete replacement of the normal fatty marrow.” The work group downgraded this potential Level III paper due to no consistent application of the gold standard. This paper provides Level IV evidence that in cases of VCF with partial replacement of the normal fatty bone marrow, MRI is more accurate than SPECT imaging in distinguishing a benign vs malignant etiology; this differentiation is not possible in VCFs with complete replacement of the normal fatty marrow.

References

1. Thariat J, Toubeau M, Ornetti P, et al. Sensitivity and specificity of thallium-201 scintigraphy for the diagnosis of malignant vertebral fractures. Eur J Radiol. 2004;51(3):274-278. doi:10.1016/j.ejrad.2003.09.014.

2. Tokuda O, Harada Y, Ueda T, Ohishi Y, Matsunaga N. Malignant versus benign vertebral compression fractures: can we use bone SPECT as a substitute for MR imaging? Nucl Med Commun. 2011;32(3):192-198. doi:10.1097/MNM.0b013e3283425665.

There is insufficient evidence to make a recommendation for or against the use of CT to differentiate osteoporotic from neoplastic vertebral compression fractures.

Grade of Recommendation: I

In a retrospective observational study, Laredo et al1 evaluated the usefulness of computed tomography (CT) as a means to differentiate benign from malignant causes of nontraumatic acute vertebral collapse (in relation to pain of less than 3 months in duration). The authors concluded that “CT can help distinguish benign from malignant causes of nontraumatic AVC.” This paper provides Level III evidence that the presence of destruction of the vertebral anterolateral or posterior cortical bone, the cancellous bone, or pedicel as well as a paraspinal soft-tissue mass or epidural mass on CT were helpful in distinguishing benign vs. malignant vertebral compression fractures.

References

1. Laredo JD, Lakhdari K, Bellaïche L, Hamze B, Janklewicz P, Tubiana JM. Acute vertebral collapse: CT findings in benign and malignant nontraumatic cases. Radiology. 1995;194(1):41-48. doi:10.1148/radiology.194.1.7997579.