This study evaluated the sensitivity, specificity, and accuracy of MRI features in differentiating vertebral compression fractures caused by malignancy, osteoporosis, or infections. 80 patients underwent MRI of 152 diagnosed vertebral fractures. MRI features suggestive of malignant fractures included a convex posterior border, pedicle involvement, posterior element involvement, epidural/paraspinal masses, and other spinal metastases. MRI features suggestive of osteoporotic fractures included retropulsion, a low signal intensity band, spared normal marrow, and the fluid sign. MRI features suggestive of infective fractures included contiguous vertebral involvement, endplate disruption, disc involvement, and paraspinal/epidural abscesses. The combination of MRI features provided clues to differentiate

1. ABSTRACT
Purpose. To evaluate the sensitivity, specificity
and accuracy of various magnetic resonance
imaging (MRI) features in differentiating vertebral
compression fractures caused by malignancy,
osteoporosis, and infections.
Methods. 35 men and 45 women aged 40 to 78
(mean, 59) years underwent MRI to assess the
underlying pathology of already diagnosed vertebral
compression fractures (n=152). The interval from
presentation to imaging ranged from 7 to 95 (mean,
62) days. MRI features of each vertebral compression
fracture were assessed. The sensitivity, specificity, and
accuracy for each of the MRI features were calculated.
Association between each MRI feature and various
underlying pathologies (malignancy, osteoporosis,
and infections) of vertebral compression fractures
was evaluated.
Results. Regarding these 80 patients, the MRI
diagnosis was correct in 78 and inconclusive in
2 with malignancy. MRI features suggestive of
Sensitivity, specificity and accuracy of
magnetic resonance imaging for differentiating
vertebral compression fractures caused by
malignancy, osteoporosis, and infections
ME Abdel-Wanis,1
Mohamed Tharwat Mahmoud Solyman,2
Nahla Mohamed Ali Hasan2
1
Department of Orthopaedic Surgery, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
2
Department of Diagnostic Radiology, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
Address correspondence and reprint requests to: Dr ME Abdel-Wanis, Department of Orthopaedic Surgery, Sohag Faculty of
Medicine, Sohag, PO 82524, Egypt. E-mail: wanis307@yahoo.com
Journal of Orthopaedic Surgery 2011;19(2):145-50
malignant fractures were a convex posterior border
of the vertebral body, pedicle involvement, posterior
neural element involvement, an epidural mass, a
paraspinal mass, and other spinal metastases. MRI
features suggestive of osteoporotic fractures were
retropulsion, low signal intensity band, spared
normal marrow signal intensity, and the fluid
sign. MRI features suggestive of infective fractures
were contiguous vertebral involvement, end plate
disruption, disc involvement, and paraspinal and
epidural abscesses.
Conclusion. Combination of several MRI features
can provide clues to differentiate between malignant,
osteoporotic, and infective vertebral compression
fractures.
Key words: fractures, compression; infection; magnetic
resonance imaging; neoplasm metastasis; osteoporosis;
osteoporotic fractures; spinal fractures
INTRODUCTION
Vertebral compression fractures are common,

2. 146 ME Abdel-Wanis Journal of Orthopaedic Surgery
especially in the elderly. Differentiating malignant
from benign compression fractures based on clinical
findings, radiography, bone scans, and computed
tomography may not be sufficient, particularly for
patients without a history of trauma or malignancy.
Magnetic resonance imaging (MRI) features
for differentiating benign and malignant spinal
compression fractures have been reported.1–5
Most
such studies only included osteoporotic fractures as
the benign entity2–4
; few included infective vertebral
fractures.5
Also, the relative importance, sensitivity,
specificity, and accuracy of several MRI criteria are
not fully established. We evaluated the sensitivity,
specificity and accuracy of various MRI features
in differentiating vertebral compression fractures
caused by malignancy, osteoporosis, or infections.
MATERIALS AND METHODS
From May 2003 to May 2007, 35 men and 45 women
aged 40 to 78 (mean, 59) years presented with back
or neck pain and/or a neurological deficit after no or
minor trauma (e.g. fall from standing height). They
underwent MRI to assess the underlying pathology
of the already diagnosed vertebral compression
fractures (n=152). The interval from presentation to
imaging ranged from 7 to 95 (mean, 62) days.
MRI was performed using a 1.5-tesla imager
(Gyro ACS.NT synergy coil MR device-Philips)
or a 0.2-tesla imager (Concerto Version syngo MR
2004A-Siemens). Gadolinium-diethylenetriamine
pentacetic acid (Gd-DTPA) of 0.2 ml/kg body weight6
was administered intravenously after conventional
T1- and T2-weighted sequences are completed.
Various MRI features of each vertebral
compression fracture were assessed. They included
(1) bone marrow replacement4,7
: (i) complete
replacement (no normal bone marrow signal in the
compressed vertebra), (ii) incomplete replacement
(some residual normal bone marrow signal), and
(iii) complete preservation (only normal bone
marrow signal); (2) convex posterior vertebral
border; (3) pedicle involvement; (4) posterior
element involvement; (5) other metastatic lesions
(denoted by abnormal signal intensity in the bone
marrow of other vertebrae)3
; (6) retropulsion of a
posterior bone fragment (often posterosuperior
angle of the vertebral body into the spinal canal)8
;
(7) a low signal intensity band–like area on T1- and
T2-weighted images corresponding to a fracture line
or trabecular impaction; (8) a fluid sign: focal, linear
or triangular areas of high signal intensity adjacent
to the vertebral end plates on T2-weighted and short
T1 inversion recovery images1,8,9
; (9) contiguous
vertebral involvement; (10) vertebral end plate
integrity; (11) vertebral disc involvement (manifest
as an abnormal signal intensity pattern: hypointense
on T1-weighted images and hyperintense on T2-
weighted and post-contrast enhancement images)
and reduced disc height; (12) epidural mass (anterior,
posterior or encasing); (13) a paraspinal soft-tissue
mass (anterior, posterior or both); (14) a paraspinal
abscess; and (15) an epidural abscess. Both abscesses
and soft-tissue masses exhibit low signal intensity
on T1-weighted images and high signal intensity
on T2-weighted images, but soft-tissue masses are
enhanced by Gd-DTPA whereas abscesses show ring
enhancement.2,10
The sensitivity (true positive / [true positive +
false negative] x100), specificity (true negative / [true
negative + false positive] x100), and accuracy (number
of correct MRI diagnosis / number of confirmed final
diagnosis x100) for each MRI feature were calculated.
Associations between each MRI feature and various
underlying vertebral compression fracture pathologies
were evaluated using the Chi squared test. A p value
of <0.05 was considered statistically significant.
Diagnostic
result
No. (%) of patients
Malignant
fractures
Osteoporotic
fractures
Infective
fractures
Correct 48 (96) 16 (100) 14 (100)
Inconclusive 2 (4) 0 0
Incorrect 0 0 0
Table 1
Diagnoses of vertebral compression fractures based on
magnetic resonance imaging (MRI)
Tumour origin No. (%) of
patients
No. (%) of
fractures
Breast 13 (26) 29 (34)
Myeloma 7 (14) 12 (14)
Liver 4 (8) 4 (5)
Lung 4 (8) 8 (9)
Lymphoma 4 (8) 8 (9)
Prostate 4 (8) 4 (5)
Thyroid 3 (6) 5 (6)
Kidney 2 (4) 2 (2)
Colon 1(2) 1 (1)
Uterus 1(2) 3 (4)
Unknown 7 (14) 9 (11)
Total 50 (100) 85 (100)
Table 2
Primary tumour diagnoses of 50 patients presented with 85
malignant vertebral compression fractures

3. Vol. 19 No. 2, August 2011 MRI for differentiating malignant, osteoporotic, and infective vertebral compression fractures 147
RESULTS
Regarding these 80 patients, the MRI diagnosis was
correct in 78 and inconclusive in 2 with malignancy
(Table 1).
In 50 patients, the underlying pathology of 85
vertebral compression fractures was malignancy
(Table 2). In 45 of them, the final diagnosis was
confirmed histopathologically through open biopsy.
In the remaining 5, it was based on progressive
deterioration of the fractured vertebra and/or new
developmentofspinalmetastasesevidentwithfollow-
up MRI. Indications for surgery were interactable
pain, neurological deficits, and a confirmed tissue
diagnosis.
In 16 patients, the underlying pathology of 34
vertebral compression fractures was osteoporosis. In
14 of them, the final diagnosis was based on clinical
and radiological follow-up over 6 to 12 months. In
the remaining 2, it was confirmed histopathologically.
Indication for surgery was neurological deficits.
In 14 patients, the underlying pathology of 33
vertebral compression fractures was infection. Their
final diagnoses were confirmed histopathologically.
The indications for surgery were interactable pain,
severe or progressive kyphosis, a large abscess, and
spinal instability.
MRI features suggestive of malignant fractures
were a convex posterior border of the vertebral
body, pedicle involvement, posterior neural element
involvement, an epidural mass, a paraspinal mass,
and other spinal metastases (Table 3 and Fig. 1).
MRI feature No. (%) of fractures (n=152) p Value Sensitivity
(%)
Specificity
(%)
Accuracy
(%)
Malignant
(n=85)
Osteoporotic
(n=34)
Infective
(n=33)
Malignant fractures
Convex posterior border 60 (71) 1 (3) 0 <0.0001 71 99 83
Pedicle involvement 81 (95) 5 (15) 15 (46) <0.0001 95 70 84
Posterior elements involvement 61 (72) 0 9 (27) <0.0001 72 87 78
Epidural mass 51 (60) 0 0 - 60 100 78
Paraspinal mass 68 (80) 4 (12) 5 (15) <0.0001 80 87 83
Other spinal metastases 65 (77) 0 0 - 77 100 87
Osteoporotic fractures
Retropulsion 0 18 (53) 2 (6) <0.0001 53 98 88
Low signal intensity band 8 (9) 28 (82) 2 (6) <0.0001 82 92 90
Spared normal marrow signal
intensity
6 (7) 27 (79) 6 (18) <0.0001 79 90 88
Fluid sign 2 (2) 12 (35) 0 <0.0001 35 98 84
Infective fractures
Contiguous vertebral involvement 20 (24) 12 (35) 29 (88) <0.0001 88 73 76
End plate disruption 4 (5) 0 27 (82) <0.0001 82 97 93
Disc involvement 2 (2) 0 32 (97) <0.0001 97 98 98
Paraspinal abscess 0 0 28 (85) - 85 100 97
Epidural abscess 0 0 24 (73) - 73 100 94
Table 3
Magnetic resonance imaging (MRI) features suggestive of malignant, osteoporotic, and infective vertebral compression
fractures
MRI features suggestive of osteoporotic fractures
were retropulsion, a low signal intensity band,
spared normal marrow signal intensity, and the fluid
sign (Table 3 and Fig. 2). MRI features suggestive
of infective fractures were contiguous vertebral
involvement, end plate disruption, disc involvement,
paraspinal abscesses, and epidural abscesses (Table 3
and Fig. 3).
DISCUSSION
MRI is superior to other diagnostic tools in
differentiating benign from malignant compression
spinal fractures,1
based on several MRI features.2–9
However, only a few studies reported the sensitivity,
specificity, and accuracy of each feature,1,3
which
enable the surgeon to prioritise the MRI features in
case of contradiction. For example in our study, the
most accurate MRI feature for diagnosis of infective
fractures was disc involvement. Its sensitivity,
specificity and accuracy were 97%, 98% and 98%,
respectively. If this feature is present, the addition of
one or 2 other features suggestive of infection will be
sufficient for diagnosis.
Combination of several MRI features strongly
affirms the diagnosis of spinal compression
fractures.1
Compared to a study in 2009,1
our study
comprised a higher number of compression fractures
(152 vs. 58), and the fractures were classified into 3
categories (malignancy, osteoporosis, and infection),
rather than 2 (malignant vs. benign) categories, in

4. 148 ME Abdel-Wanis Journal of Orthopaedic Surgery
Figure 1 (a) Sagittal T1-weighted, (b) T2-weighted (c) short T1 inversion recovery, and (d) axial (L5) T2-weighted magnetic
resonance images (MRI) of the lumbosacral spine in a 46-year-old woman: the compression fracture of the L5 vertebral body
shows complete replacement of normal marrow signal intensity, convex posterior border (arrows), involvement of the pedicles
and transverse processes (asterisk), and metastases affecting L3 and L4 vertebrae (arrowheads). The MRI diagnosis is metastases
affecting L3, L4, and L5 vertebrae complicated with compression fracture of L5. The final diagnosis is metastatic compression
fracture of L5 originating from breast cancer.
Figure 2 Sagittal (a) T1-weighted, (b) T2-weighted, (c) short T1 inversion recovery, and (d) axial (L2 and L3) T2-weighted
magnetic resonance images (MRI) of the lumbosacral spine in a 60-year-old woman: compression fractures of L2 and L3 show
anterior wedging of the L2 vertebral body, low signal fracture line at L2 and L3, fluid sign at L3, and incomplete replacement
of normal marrow signal intensity. The MRI diagnosis is L2 and L3 acute osteoporotic compression fractures, which is also the
final diagnosis.
(a) (d)(b) (c)
(a) (d)(b) (c)
which the benign category (23 patients) included
trauma and infection. In our study, the final diagnosis
in 75% of patients was based on biopsy, compared to
22%.
Biopsy is the gold standard for final diagnosis
of vertebral compression fractures. A study
reported 3 patients who were provisionally
diagnosed as having osteoporotic fracture, which
was discovered by biopsy during vertebroplasty
and kyphoplasty to be malignant fractures caused
by lymphoma.11
In another study, the presumed
aetiology in 18% of cases was not confirmed
on pathological examination.12
In fact, a biopsy
picture suggestive of chronic osteomyelitis was
reported in 6 (11%) out of 66 patients diagnosed
as having osteoporotic spinal fractures.13
Because
the accuracy of percutaneous vertebral biopsy
was reported to be 80 to 90%,14
our study should
be considered accurate, as diagnoses of 75% of
patients were made by open biopsy.
Our study may help develop an MRI score
to differentiate compression fractures caused by

5. Vol. 19 No. 2, August 2011 MRI for differentiating malignant, osteoporotic, and infective vertebral compression fractures 149
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