Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care
Diagnosis and Treatment of Adults with Osteoporotic Vertebral Fractures
Recommendations:
Imaging Diagnosis
Imaging Diagnosis Question 1: Which imaging modalities and findings are most sensitive and specific for the accurate diagnosis of symptomatic osteoporotic vertebral compression fractures?
Flexion/extension radiographs are suggested as an option for diagnosing acute osteoporotic vertebral compression fractures when MRI cannot be obtained.
Grade of Recommendation: B
In a comparative study, Chen et al1 aimed to find the diagnostic value of dynamic radiographs and the percentage of mobile vertebrae in difficult vertebral compression fractures. The authors concluded that “dynamic (sitting and supine with bolster) radiographs can be valuable in diagnosing painful vertebrae in VCFs”. This paper provides Level II evidence that dynamic upright and stress supine X-rays are helpful to diagnose acute painful vertebral fractures. In a comparative study, Niimi et al2 assessed the diagnostic validity of comparative supine and sitting lateral radiographs for diagnosing acute osteoporotic vertebral fractures, which can be used to evaluate its effectiveness for predicting any ensuing reduction in vertebral height. The authors concluded that “dynamic radiographs provide a convenient way to identify acute OVFs”. The work group downgraded this potential Level II paper due to nonconsecutive patients and nonmasked reviewers. This paper provides Level III evidence that acute symptomatic OVCF can be diagnosed two-thirds of the time with dynamic mobility on X-ray. References: 1. Chen YJ, Lo DF, Chang CH, Chen HT, Hsu HC. The value of dynamic radiographs in diagnosing painful vertebrae in osteoporotic compression fractures. AJNR Am J Neuroradiol. 2011;32(1):121-124. doi:10.3174/ajnr.A2233 2. Niimi R, Kono T, Nishihara A, et al. Efficacy of the dynamic radiographs for diagnosing acute osteoporotic vertebral fractures. Osteoporos Int. 2014;25(2):605-612. doi:10.1007/s00198-013-2456-9
Scintigraphy (bone scan) is suggested as an alternative imaging modality to diagnose acute osteoporotic vertebral compression fractures when MRI cannot be obtained.
Grade of Recommendation: B
In a retrospective case series study, Karam et al1 aimed to determine the reliability of bone scanning in patient selection, planning treatment and foretelling response to kyphoplasty. The authors concluded that “bone scanning is an excellent predictor of response to kyphoplasty and decreases the number of vertebrae to be treated as suggested by X-ray. Preoperative bone scanning is recommended to avoid incorrect selection of treatment level. Even when the appropriate level has been selected an incomplete response can be expected if additional chronic fracture is seen on bone scanning. In the event of unexpected incomplete response, re-evaluation with bone scanning may demonstrate new disease amenable to therapy.” This paper provides Level II evidence that positive bone scans will reliably predict a painful vertebral level that will respond favorably to KP. Zhao et al2 prospectively assessed the value of radionuclide bone imaging in the diagnosis of new OVCFs. The authors concluded that “radionuclide bone imaging can accurately distinguish fresh and old vertebral compression fractures, with consistency between radionuclide bone imaging and MRI.” The work group downgraded the level of evidence due to small sample size, nonconsecutive patients, and nonmasked reviewers. This paper provides Level III evidence that a bone scan is highly accurate in detecting OVCF compared to an MRI. In a prospective case series study, Li et al3 analyzed the difference in consistency between SPECT CT and an MRI when it comes to identifying active lesions in patients with OVCFs. The authors concluded “SPECT-CT is the preferred method for imaging diagnosis when patients with suspected OVCFs have contraindications to MRI, particularly for patients with acute fractures.” This paper provides Level III evidence that SPECT CT have been useful in the diagnosis of PVCF. References: 1. Karam M, Lavelle WF, Cheney R. The role of bone scintigraphy in treatment planning, and predicting pain relief after kyphoplasty. Nucl Med Commun. 2008;29(3):247-253. doi:10.1097/MNM.0b013e3282f30598 2. Zhao QM, Gu XF, Liu ZT, Cheng L. The Value of Radionuclide Bone Imaging in Defining Fresh Fractures Among Osteoporotic Vertebral Compression Fractures. J Craniofac Surg. 2016;27(3):745-748. doi:10.1097/SCS.0000000000002594 3. Li YB, Zheng X, Wang R, et al. SPECT-CT versus MRI in localizing active lesions in patients with osteoporotic vertebral compression fractures. Nucl Med Commun. 2018;39(7):610-617. doi:10.1097/MNM.0000000000000857
There is insufficient evidence to make a recommendation for or against dual-energy CT for the diagnosis of acute osteoporotic vertebral compression fractures.
Grade of Recommendation: I
In a retrospective case series study, Kaup et al1 assessed whether a dual-energy CT virtual noncalcium technique can be used to improve the rate of detection of acute thoracolumbar vertebral compression fractures in patients with osteoporosis compared to that of an MRI. The authors concluded that “the DE CT–based virtual noncalcium technique may enable depiction of bone marrow edema in thoracolumbar vertebral compression fractures in patients with osteoporosis, with good accordance with MR imaging when images are read by experienced radiologists. Although less experienced readers improved their diagnostic performance to some degree, the experienced reader’s diagnostic performance approached that with MR imaging.” This paper provides Level III evidence that the sensitivity, specificity, accuracy, PPV and NPV of detecting vertebral bone marrow edema is closer to MRI with dual-energy CT compared to conventional CT.
References: 1. Kaup M, Wichmann JL, Scholtz JE, et al. Dual-Energy CT-based Display of Bone Marrow Edema in Osteoporotic Vertebral Compression Fractures: Impact on Diagnostic Accuracy of Radiologists with Varying Levels of Experience in Correlation to MR Imaging. Radiology. 2016;280(2):510-519. doi:10.1148/radiol.2016150472
There is insufficient evidence to make a recommendation for or against the use of radiographs for diagnosing acute osteoporotic vertebral compression fractures.
Grade of Recommendation: I
In a retrospective case series study, Marongiu et al1 quantified the misdiagnosis rate of OVCFs, as well as evaluate and compare the impact of MRI on early diagnosis and classification in relation to standard radiographs. The authors concluded that “underdiagnosis of osteoporotic vertebral fractures is a common problem due to a lack of radiographic detection. Our results showed that the extensive use of MRI imaging allows better accuracy in the diagnostic process and in the classification assessment, compared to conventional radiographs.” This paper provides Level I evidence that radiographs have low sensitivity and specificity and accuracy for diagnosing acute symptomatic OVCF.
References: 1. Marongiu G, Congia S, Verona M, Lombardo M, Podda D, Capone A. The impact of magnetic resonance imaging in the diagnostic and classification process of osteoporotic vertebral fractures. Injury. 2018;49 Suppl 3:S26-S31. doi:10.1016/j.injury.2018.10.006
FLASK Future Directions for Research
The work group recommends high-quality studies evaluating the use of dual-energy CT or other promising imaging modalities for the diagnosis of acute OVCF, as an alternative to MRI.
Interventional Treatment Question 2: Which imaging findings stratify the acuity of osteoporotic vertebral compression fractures?
It is suggested that the presence of a fluid sign or edema in dual energy CT scan can differentiate new or acute osteoporotic vertebral compression fractures from older fractures.
Grade of Recommendation: B
In a retrospective comparative study, Kaup et al1 compared a magnetic resonance (MR) imaging and a dual-energy (DE) computed tomographic (CT) virtual noncalcium technique in improving the rate of detection of an acute thoracolumbar vertebral compression fracture (VCF) in patients with osteoporosis (considering the experience of the reading radiologist). The authors concluded that “The DE CT–based virtual noncalcium technique may enable depiction of bone marrow edema in thoracolumbar vertebral compression fractures in patients with osteoporosis, with good accordance with MR imaging when images are read by experienced radiologists. Although less experienced readers improved their diagnostic performance to some degree, the experienced reader’s diagnostic performance approached that with MR imaging.” This paper provides Level III evidence that bone marrow edema (as seen on virtual noncalcium DE CT) can improve detection rates of new/acute thoraco-lumbar OVCF (and bone bruise) and help distinguish from older fractures in readers with experience with DECT. In a retrospective comparative study, Schwaiger et al2 evaluated whether patients with acute vertebral fractures, who had a bone marrow edema, could be correctly diagnosed from a 3-material decomposition with dual-layer spectral CT (DLCT). The authors concluded that “Material decomposition of DLCT data substantially improved accuracy for the diagnosis of acute vertebral fractures, with a high interreader agreement. This may spare patients additional examinations and facilitate the diagnosis of vertebral fractures.” This paper provides Level III evidence that bone marrow edema detection on dual-layer spectral CT (DLCT) can be achieved with near similar accuracy as MRI in patients with thoracolumbar OVCF. References: 1. Kaup M, Wichmann JL, Scholtz JE, et al. Dual-Energy CT-based Display of Bone Marrow Edema in Osteoporotic Vertebral Compression Fractures: Impact on Diagnostic Accuracy of Radiologists with Varying Levels of Experience in Correlation to MR Imaging. Radiology. 2016;280(2):510-519. doi:10.1148/radiol.2016150472 2. Schwaiger BJ, Gersing AS, Hammel J, et al. Three-material decomposition with dual-layer spectral CT compared to MRI for the detection of bone marrow edema in patients with acute vertebral fractures. Skeletal Radiology. 2018;47(11):1533-1540.
There is insufficient evidence to make recommendation for or against the use of the vacuum sign cleft on radiographs or bone scan to confirm a nonunion painful fracture.
Grade of Recommendation: I
In a retrospective comparative study, Lin et al1 compared the findings between a plain film, bone scan, and magnetic resonance imaging (MRI) when it comes to diagnosing a new fracture in osteoporotic vertebral fractures. The authors concluded “For patients with single-level compression fracture, the painful level in osteoporotic vertebral fractures can be determined by plain film and bone scan testing. Vacuum cleft sign noted on plain film may be enough to localize the level of pain. However, MRI testing is further needed in multiple osteoporotic vertebral fracture patients.” This paper provides Level III evidence that that vacuum sign cleft can be determined with equal accuracy on plain X-ray or bone scan (compared to MRI) especially for single-level involvement. For multiple levels, confirmation testing with MRI is warranted. References: 1. Lin HH, Chou PH, Wang ST, Yu JK, Chang MC, Liu CL. Determination of the painful level in osteoporotic vertebral fractures--Retrospective comparison between plain film, bone scan, and magnetic resonance imaging. J Chin Med Assoc. 2015;78(12):714-718. doi:10.1016/j.jcma.2015.06.015
FLASK Future Directions for Research
The work group recommends further high-quality studies using dual energy CT to confirm and validate the above recommendations.