7.4 Spine Radiography & Fracture Follow-up
Key Takeaways
Conventional lateral spine radiography shows vertebral structure and shape. A radiograph does not supply BMD or a T-score.
Consider further imaging for equivocal VFA, an unidentified T7–L4 level, or a deformity with features suggesting another cause.
Use clinical history, projection quality and prior images to distinguish a fracture from longstanding developmental or degenerative changes.
Select a radiograph for the structural question
Conventional spine radiography shows vertebral shape, cortical margins and endplates, alignment, and intervertebral spaces. A lateral thoracic or lumbar view profiles vertebral heights. It can show a vertebral compression fracture even when the dual-energy X-ray absorptiometry (DXA) T-score is above −2.5. A radiograph does not measure bone mineral density (BMD) or supply a T-score. A qualitative impression of low bone density on an X-ray may prompt assessment, but the visual impression cannot substitute for a valid densitometric measurement.
The 2023 International Society for Clinical Densitometry (ISCD) adult positions permit standard lateral spine radiography or densitometric vertebral fracture assessment (VFA) when the adult lateral-imaging indications are met. Conventional radiography is also useful when the relevant VFA level cannot be seen, or when a possible fracture needs better anatomical detail. A lateral chest radiograph obtained for another reason may show an incidental vertebral fracture. If visible, such a finding should be communicated and considered in the clinical assessment. A chest image obtained for another indication may not cover or adequately display the entire thoracolumbar spine.
Check coverage, projection and morphology
- Choose coverage to match the clinical question. A dedicated thoracic or lumbar examination should show the requested anatomy. Include enough adjacent landmarks for numbering, particularly around the thoracolumbar junction. Additional projections may be appropriate for a difficult level, depending on the radiography protocol.
- Verify the lateral projection. Obliquity can separate superimposed endplates and make one margin appear shorter. Review whether vertebral boundaries are well enough seen for diagnosis. If a level is not interpretable, report the limitation.
- Compare vertebrae and earlier images. Look at anterior, middle and posterior heights, cortical/endplate shape, and adjacent discs and levels. A prior study helps distinguish a stable deformity from an interval change. A solitary radiograph may not establish fracture acuity.
- Look for other explanations. Smooth developmental wedging, the pattern of Scheuermann disease, degenerative remodeling, and an off-axis view may mimic fracture. Focal destructive change, unusual sclerosis or an abnormal paravertebral appearance can indicate a process requiring diagnostic workup rather than classification as an osteoporotic fracture.
Decide whether additional imaging is needed
| Finding or setting | What to do with the imaging finding |
|---|---|
| Equivocal deformity or an unidentified level from T7 through L4 on adult VFA | Consider further imaging in the clinical context. A dedicated lateral radiograph can provide a more detailed view of the level. |
| Lytic, sclerotic or otherwise unexplained vertebral finding, or relevant malignancy with a deformity on VFA | Arrange appropriate diagnostic assessment rather than using VFA to characterize the lesion. The choice of radiographs, CT or MRI depends on the clinical question. |
| New symptomatic vertebral compression fracture already seen on radiographs in an adult without known malignancy | ACR considers CT without contrast or MRI without contrast of the area usually appropriate as the next study. CT shows bony detail and MRI can help evaluate marrow and acuity. |
| Persistent high risk after the original study | ISCD allows follow-up lateral radiography or VFA in patients with continued high risk. Specify the clinical reason and compare with prior imaging where possible. |
Worked imaging decision
A 76-year-old woman with a femoral neck T-score of −1.8 has an equivocal T8 deformity on VFA. The vertebral margins are obscured by overlapping anatomy. Record the limited view and consider dedicated lateral thoracic radiography to clarify morphology. If the radiograph confirms an interval compression fracture and the patient has new focal pain, the next question may concern acuity, posterior wall involvement or another cause. In that setting CT or MRI may be appropriate. A second BMD number cannot answer the structural question.
In a different case, several neighboring vertebrae show similar anterior wedging, irregular endplates and Schmorl nodes. The patient has a long history of thoracic kyphosis dating to adolescence. This pattern supports considering Scheuermann disease as a fracture mimic. Review prior images and the clinical history before calling three new fragility fractures. If the image remains equivocal, communicate the uncertainty and obtain additional imaging when it would change care.
ISCD Adult Official Positions · ACR Spine Radiography Practice Parameter · ACR Vertebral Compression Fracture Criteria · IOF Vertebral Fracture Assessment
A lateral image shows similar anterior wedging and irregular endplates with Schmorl nodes at three adjacent thoracic levels. The patient has a history of adolescent thoracic kyphosis. What is the most appropriate interpretation?
Three acute fragility fractures are established by the height measurements alone.
The pattern confirms blastic metastatic disease.
Consider Scheuermann disease as a fracture mimic and review the history and prior images. Obtain further imaging if uncertainty would change care.
This is a lumbar Cupid’s bow deformity.
A VFA image shows an equivocal T8 deformity, with overlapping anatomy obscuring the endplate. Which study can provide a dedicated view of its shape?
A lateral thoracic spine radiograph.
A total hip DXA.
A repeat femoral neck T-score calculation.
A one-third radius DXA.
Sections you finish are checked off in the contents.