Pictorial ReviewMalignant and benign compression fractures: differentiation and diagnostic pitfalls on MRI
Introduction
Differentiation between malignant (pathological) and benign vertebral compression fractures is often problematic. This is particularly difficult in the elderly patients who are predisposed to benign compression fractures caused by osteoporosis. In this group a benign fracture can result from minor trauma and make the interpretation of the lesion difficult if there is a known primary malignancy elsewhere. Establishing the correct diagnosis is of great importance in determining treatment and prognosis.
In addition to osteoporosis other causes of benign compression fracture include trauma, eosinophilic granuloma, Paget's disease, haemangioma, etc. Malignant compression fracture can be either metastatic or primary (bone tumours, multiple myeloma, malignant lymphoma, leukaemia etc.).
Traditionally radiography, bone scintigraphy and computed tomography (CT) have been used for the diagnostic work-up of patients with compression fracture. However, at times these techniques are inadequate for identifying the cause of the compression fractures. Recently magnetic resonance imaging (MRI) has been increasingly used for the evaluation of these fractures. Reliable MRI criteria based on changes in the signal intensity and the morphology of the collapsed vertebra has been established for differentiating benign from malignant compression fractures. The purpose of this review is to describe the salient features of malignant and benign compression fractures on MRI.
Section snippets
Malignant compression fracture
On spin-echo T1-weighted images (T1WI) a malignant compression fracture shows complete replacement of normal bone marrow with diffuse low signal intensity in the whole of vertebral body (Figure 1, Figure 2).1., 2., 3., 4., 5., 6. On spin-echo T2 weighted images (T2WI) iso to high signal intensity is seen in the collapsed vertebra (Fig. 1); the distribution of signal intensity can either be homogeneous4 or heterogeneous.1 Abnormal enhancement is seen in the vertebrae on post-contrast medium
Benign compression fracture
Signal intensity of a benign compression fracture varies according to the age of the fracture. Acute osteoporotic fractures (<2 months old) characteristically show a focal band-like area of low signal intensity adjacent to the fractured endplate on T1WI (Fig. 4).1., 2. At least one area of normal signal intensity is seen within the collapsed vertebra. These areas of normal signal intensity are usually located opposite the fractured endplate and can have variable shapes (Fig. 5).1 On T2WI, a
Imaging sequences on MRI
Although conventional imaging sequences (T1 and T2 fast spin-echo) are often enough to make a distinction between malignant and benign compression fractures, additional sequences, such as STIR and fat-suppressed T2WI, can be used for more clear delineation of abnormalities as they give higher contrast between normal and abnormal marrow. A few studies based on a small number of patients have used newer sequences and approaches like dynamic imaging16 and diffusion-weighted imaging17 for the
Pitfalls of MRI
Compression fracture in patients with multiple myeloma, although most likely malignant in pathogenesis, frequently has the appearance of benign osteoporotic fracture on MRI (Fig. 9).18 Only a small percentage of these fractures show MRI features of malignant fracture. Hence multiple myeloma should be considered in the differential diagnosis of non-traumatic, benign-appearing vertebral compression fracture.
Acute traumatic fracture shows diffuse low signal intensity on T1WI and is often
Conclusion
Homogeneous and diffuse abnormal signal intensity, posterior convexity, and involvement of pedicles are signs that are strongly suggestive of malignant compression fracture. Conversely, a band-like area of low signal intensity adjacent to the depressed endplate or preservation of signal intensity of the vertebra suggests benign nature of the collapse. By applying the constellation of morphological and signal intensity criteria the nature of the majority of compression fractures can be correctly
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