Lumbar Compression Fracture Workup
- Author: Andrew L Sherman, MD, MS; Chief Editor: Stephen Kishner, MD, MHA more...
Perform a complete blood cell count with differential, prostate-specific antigen testing (in middle-aged and older men), and erythrocyte sedimentation rate determination.
Serum protein electrophoresis is indicated in selected cases, to assess for multiple myeloma.
The urine can be sampled for markers of increased bone turnover, which occur in persons with osteoporosis. In specific cases, urine for Bence-Jones proteins is necessary to search for multiple myeloma.
Radiography is the standard imaging study for spine fractures. Anteroposterior and lateral views of the lumbar and thoracic spines are usually the minimum studies needed. Evaluation of the entire spine is important because up to 20% of all spinal fractures are multiple. Additionally, lateral flexion and extension studies, standing if possible, can be helpful to look for gross instability.
In burst fractures, the lateral radiograph may show decreased vertebral body height. The anteroposterior view is important because the presence of increased interpedicular space may indicate an unstable fracture.
Computed tomography (CT) scanning
CT scanning is an invaluable tool to evaluate the complexity of fractures seen on radiographs and to spot subtler fractures not readily seen on radiographs. CT scanning accurately visualizes the amount of spinal canal compromise and middle canal involvement.
All patients with wedge fractures with more than 50% loss of vertebral height should undergo CT scanning to rule out middle column and burst fractures. In one study, 25% of fractures diagnosed initially as wedge fractures were actually burst fractures. Sagittal reconstructions can add information to the plain axial study.
Finally, CT scanning is the best test to visualize fractures of the posterior elements and laminae of the neural arch.
A study by Karaca et al indicated that dual energy CT scanning is comparable to MRI with regard to identifying vertebral compression fractures after acute trauma. In identifying vertebral edema, dual energy CT scanning had, when MRI was used as the reference standard, a sensitivity, specificity, positive-predictive value, negative predictive value, and accuracy of 89.3%, 98.7%, 95.4%, 96.9%, and 96.6%, respectively.
MRI is required when the patient describes lower extremity motor or sensory loss. Radicular pain is another indication for MRI. Also, when canal compromise is suspected, MRI is required.
MRI is important because it produces the best visualization of the neural structures of the spine. Additionally, MRI, when performed with contrast enhancement, can visualize hemorrhage, tumor, and infection with the greatest sensitivity.
Dual energy radiographic absorptiometry (DRA) scanning
DRA scanning is currently the most widely used method to measure bone mineral density. The American College of Radiology recommends posterior-anterior spine DRA as the most appropriate study for the identification of low bone density and fracture risk in postmenopausal women older than 50 years and men older than 50 with risk factors for osteoporosis.
When compared with radiographic absorptiometry or single energy radiographic absorptiometry, DRA scanning more precisely documents small changes in bone mass and is also more flexible because it can be used to examine both the spine and the extremities.
Studies using DRA scanning have shown that people with osteoporosis have substantially lower bone density measurements than healthy, age-matched people.
DRA scanning can be used to assess the response to treatment of osteoporosis over time.
Positron emission tomography (PET) scanning
PET scanning has been used to differentiate benign compression fractures from malignant ones. However, therapy with bone marrow–stimulating agents may result in false-positive scans for malignant fracture.
When malignancy is strongly suspected, a vertebral biopsy is indicated. These biopsies are usually performed under CT guidance. However, vertebral biopsy should not be performed when the suspected tumor is a chordoma or other aggressive primary spine tumor that spreads via direct extension.
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