0:01

This was a patient in her 60s who presented after

0:05

a motor vehicle collision with back pain.

0:08

When we looked at the CT scan, we didn't have old studies,

0:13

and we were perplexed about the possibility

0:16

of an acute injury to the L4 vertebra.

0:20

We really didn't see anything else in the

0:22

lumbar spine that was of concern.

0:25

This patient has some element of sclerosis

0:28

of the superior endplate of L4,

0:32

and it was unclear whether this was an acute injury or a

0:35

prior injury without the existence of comparison films.

0:40

This is the axial scan through that fracture,

0:44

and you notice that a little bit of fragmentation

0:47

anteriorly and on the right side,

0:48

as well as irregularity to the density of the vertebral body

0:53

at L4. So going into this, because of the sclerosis,

0:59

we were thinking that this was an old injury.

1:02

This is the thicker section images.

1:05

And one thing to look for on thick section images

1:08

as well as in the soft tissue windows,

1:10

is to see whether there's any edema in the paraspinal

1:14

space that might suggest that this is an acute injury.

1:19

So let's look at the MRI scan to determine whether

1:22

or not the fracture was acute or not.

1:27

I want to just make one comment as we go to the MRI scan.

1:31

Notice the L1 vertebra,

1:34

which was thought to be normal on the CT scan.

1:39

MRI is quite useful for the evaluation of compression

1:43

fractures of the spine. Because we see compression

1:47

fractures both chronically as well as acutely,

1:51

you need to try to make this distinction when a patient with

1:54

a motor vehicle collision who's in the elderly

1:57

age group complains of back pain.

2:00

So if you were looking at the T1-weighted scan here,

2:03

and you notice that there's a little bit of compression

2:05

deformity of the L1 vertebra and the L4 vertebra,

2:09

you might ask, well,

2:10

are these acute or is this a chronic process?

2:14

Because osteoporotic compression fractures are that common.

2:18

Looking at the T2-weighted scan,

2:21

we would look at this and say, oh, well,

2:23

there's not really bone edema on the T2-weighted scan,

2:27

and this also looks a little bit dark in signal intensity.

2:31

So maybe these are chronic fractures.

2:34

This points out the incredible value of the STIR image.

2:38

The STIR image is the most sensitive

2:40

for identifying bone edema.

2:43

And what you see on the STIR image is that indeed the L1

2:47

vertebra is bright compared to the normal signal intensity,

2:51

and the L4 vertebra is bright compared to the normal

2:56

dark signal intensity. The adjacent discs are somewhat

3:00

right, and that may be reactive.

3:01

So these are indeed acute compression fractures that are

3:06

occurring at L1 and L4 demonstrated very

3:09

nicely on the STIR imaging.

3:12

I would, however,

3:14

look back at any abdominal pelvic CT scan or thoracic, or

3:20

lumbar spine CT scan to see whether you see this on

3:25

prior imaging. Despite the fact that STIR is so good,

3:29

I would still utilize prior imaging in order to determine

3:33

whether this is an acute fracture

3:36

or one that was preexisting.

Case 34 - Compression Fracture

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