The imaging workup of patients being considered for vertebroplasty can be done in several ways. The simplest type of preprocedural imaging is a plain film study, and is a good starting point in patients who have sudden onset of acute back pain, particularly when it is associated with minor trauma. In osteoporotic female patients with a new compression fracture noted on serial films, focal pain, point tenderness, lack of spinal stenosis or fragment ret-ropulsion, and no history of malignancy, proceeding directly to vertebroplasty is appropriate. Although osteo-porotic compression fractures occur in men, the lifetime risk of a symptomatic fracture is only 5% for males (32). A compression fracture in a male patient with no underlying cause for osteoporosis, for example, steroid use, should raise a flag to the evaluator, and performing magnetic resonance imaging (MRI) to exclude a malignancy is reasonable.

Patients with single, uncomplicated fractures comprise the minority of our practice. Typically, multiple fractures of uncertain age are seen in conjunction with a new fracture. Even in the setting of a fairly straightforward physical examination, it is often useful to review serial plain films and obtain adjunctive imaging. This can be done either with MRI or bone scan imaging, although computed tomography (CT) may be helpful in some cases. Bone scan has been shown to be extremely useful in pinpointing which are the painful fracture levels in the setting of multiple fractures (33). In these cases, treating the levels that demonstrate increased activity on bone scan imaging is associated with a high likelihood of pain relief (Fig. 1). Conversely, it is reasonable to perform MRI to look for edema, particularly on short tau inversion recovery (STIR) images (Fig. 2), or for enhancement on fat-saturated, gadolinium enhanced T1-weighted images (34). MRI has the advantage of offering morphologic evaluation of suspected canal compromise from retro-pulsed fragments, recognition of concomitant processes such as herniated discs, and detection of malignancies. However, in straightforward cases, either a bone scan or MRI would be considered appropriate in most cases of multilevel fracture.

CT scanning has relatively little relevance in the prepro-cedure workup of patients being considered for vertebroplasty. CT is best used for evaluation of complex fractures, where the fracture lines may significantly involve the pedicles or posterior wall, and for osteolytic processes such as metastases. It may also be useful in the evaluation of hemangiomas with significant bony loss (Fig. 3).

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