American College of Radiology
ACR Appropriateness Criteria®

Management of Vertebral Compression Fractures

Variant 1: New symptomatic compression fracture identified on radiographs or CT. No known malignancy.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Strong 3 07 N/A N/A 8 8 0 0 0 1 0 0 3 4 6
References Study Quality
61 (24077202) 3
65 (1627411) 4
64 (1836154) 4
63 (19657122) 1
62 (19478654) 1
19 (27544377) 1
MRI spine area of interest without IV contrast Usually appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 8 8 1 0 0 0 1 0 2 4 6
References Study Quality
48 (16687528) 2
47 (25946722) 2
41 (21162942) 2
46 (21217433) 2
45 (21779855) 4
40 (19282740) 4
42 (19504131) 4
44 (18831901) 2
43 (23619191) 2
CT spine area of interest without IV contrast Usually appropriate Strong 3 07 Varies Varies Varies Varies 7 7 0 0 0 1 5 0 3 3 2
References Study Quality
39 (26928067) 2
38 (26537691) 2
36 (22091375) 4
9 (14519867) 4
37 (28065376) 2
Percutaneous vertebral augmentation May be appropriate Strong 3 07 N/A N/A 6 6 0 0 0 0 4 5 1 4 0
References Study Quality
79 (18989668) 2
75 (16429288) 4
81 (22194515) 2
70 (19657121) 1
71 (20701962) 1
73 (19246088) 1
66 (10529144) 2
63 (19657122) 1
67 (9536480) 4
72 (20190623) 1
62 (19478654) 1
69 (9403451) 4
33 (24325929) 4
31 (22116114) 2
85 (19829253) 3
83 (20372942) 3
80 (20625321) 2
84 (21076886) 3
20 (21375382) 1
30 (23021641) 1
77 (23391839) 3
78 (25404372) 2
74 (25787683) 2
19 (27544377) 1
76 (27400110) 2
82 (26630417) 1
Tc-99m bone scan whole body May be appropriate Strong 1 04 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 0 1 1 12 1 1 0 0
References Study Quality
52 (26364958) 3
49 (22927151) 3
53 (21165311) 3
51 (18349795) 2
50 (20706042) 3
Surgical consultation May be appropriate Expert Consensus 1 N/A N/A 5 5 0 0 0 4 5 2 2 0 1
Tc-99m SPECT/CT spine area of interest May be appropriate Limited 1 5 5 0 0 1 0 13 1 0 1 0
References Study Quality
55 (24694774) 3
54 (23559712) 4
56 (22208854) 2
FDG-PET/CT skull base to mid-thigh Usually not appropriate Limited 1 ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 3 3 7 0 0 2 4 0 0 1 0
References Study Quality
60 (3277565) 4
58 (11914890) 4
59 (12811277) 1
57 (12195540) 4
MRI spine area of interest without and with IV contrast Usually not appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 2 2 6 2 4 0 1 0 0 0 1
References Study Quality
48 (16687528) 2
47 (25946722) 2
41 (21162942) 2
46 (21217433) 2
45 (21779855) 4
40 (19282740) 4
42 (19504131) 4
44 (18831901) 2
43 (23619191) 2
MRI spine area of interest with IV contrast Usually not appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 2 2 7 2 3 0 1 0 1 0 0
References Study Quality
48 (16687528) 2
47 (25946722) 2
41 (21162942) 2
46 (21217433) 2
45 (21779855) 4
40 (19282740) 4
42 (19504131) 4
44 (18831901) 2
43 (23619191) 2
CT spine area of interest without and with IV contrast Usually not appropriate Strong 3 07 Varies Varies Varies Varies 1 1 8 3 2 0 1 0 0 0 0
References Study Quality
39 (26928067) 2
38 (26537691) 2
36 (22091375) 4
9 (14519867) 4
37 (28065376) 2
CT spine area of interest with IV contrast Usually not appropriate Strong 3 07 Varies Varies Varies Varies 1 1 8 2 3 0 1 0 0 0 0
References Study Quality
39 (26928067) 2
38 (26537691) 2
36 (22091375) 4
9 (14519867) 4
37 (28065376) 2
Percutaneous thermal ablation Usually not appropriate Limited 3 N/A N/A 1 1 12 0 2 0 0 0 0 0 0
References Study Quality
86 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus 1 N/A N/A 1 1 10 1 1 1 1 0 0 0 0
Variant 2: Osteoporotic compression fracture, with or without edema on MRI and no “red flags”. With or without spinal deformity, worsening symptoms, or pulmonary dysfunction.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Limited 1 N/A N/A 8 8 1 0 0 0 2 0 2 3 6
References Study Quality
68 (13677812) 4
66 (10529144) 2
65 (1627411) 4
64 (1836154) 4
67 (9536480) 4
69 (9403451) 4
Percutaneous vertebral augmentation Usually appropriate Strong 3 07 N/A N/A 7 7 0 1 0 0 4 2 3 3 1
References Study Quality
90 (8324411) 4
89 (10892628) 4
79 (18989668) 2
61 (24077202) 3
1 (8324412) 4
81 (22194515) 2
33 (24325929) 4
31 (22116114) 2
80 (20625321) 2
20 (21375382) 1
29 (22628598) 3
92 (24077200) 2
14 (24253785) 1
18 (24315046) 1
91 (24744201) 3
Surgical consultation Usually not appropriate Expert Consensus 1 N/A N/A 3 3 3 2 3 2 2 1 0 1 0
Percutaneous thermal ablation Usually not appropriate Limited 3 N/A N/A 1 1 12 1 0 0 1 0 0 0 0
References Study Quality
86 (18566009) 4
Radiation oncology consultation Usually not appropriate Expert Consensus 1 N/A N/A 1 1 9 2 2 0 1 0 0 0 0
Variant 3: Painful osteoporotic compression fracture with edema on MRI. Contraindication to vertebral augmentation or surgery (eg, fitness, pregnancy, infection, coagulation disorder, etc.).
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Medical management Usually appropriate Expert Consensus 1 N/A N/A 9 9 0 0 0 0 0 0 1 2 11
Surgical consultation May be appropriate Expert Consensus 1 N/A N/A 5 5 0 0 0 2 7 2 2 0 1
Radiation oncology consultation Usually not appropriate Expert Consensus 1 N/A N/A 1 1 11 1 2 0 0 0 0 0 0
Variant 4: Known malignancy and new back pain. Compression fracture identified on radiographs or CT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
MRI spine area of interest without and with IV contrast Usually appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 9 9 0 0 0 0 0 0 2 4 8
References Study Quality
13 (20809724) 4
109 (27441748) 4
101 (21857034) 3
108 (26204297) 4
107 (19530588) 3
106 (20580503) 3
104 (26376170) 4
103 (28670417) 3
102 (24484060) 2
81 (22194515) 2
110 (23960179) 4
Image-guided biopsy spine area of interest Usually appropriate Expert Consensus 1 Varies Varies Varies Varies 7 7 0 0 0 1 5 1 2 4 1
FDG-PET/CT skull base to mid-thigh May be appropriate Limited 1 ☢☢☢☢ 10-30 mSv ☢☢☢☢☢ 10-30 mSv [ped] 6 6 0 0 0 0 6 4 2 1 1
References Study Quality
114 (27694173) 4
58 (11914890) 4
59 (12811277) 1
57 (12195540) 4
113 (23251117) 4
Tc-99m bone scan whole body May be appropriate Expert Consensus 1 ☢☢☢ 1-10 mSv ☢☢☢☢ 3-10 mSv [ped] 5 5 0 1 0 1 8 3 0 2 0
MRI spine area of interest without IV contrast May be appropriate (Disagreement) Expert Opinion 2 O 0 mSv O 0 mSv [ped] 5 6 0 0 2 1 4 2 4 1 1
References Study Quality
13 (20809724) 4
109 (27441748) 4
101 (21857034) 3
108 (26204297) 4
107 (19530588) 3
106 (20580503) 3
104 (26376170) 4
103 (28670417) 3
102 (24484060) 2
81 (22194515) 2
110 (23960179) 4
Tc-99m SPECT/CT spine area of interest May be appropriate Limited 3 5 5 1 0 0 3 8 2 0 1 0
References Study Quality
112 (18993040) 3
111 (8254410) 3
MRI spine area of interest with IV contrast May be appropriate Strong 3 07 O 0 mSv O 0 mSv [ped] 4 4 3 0 4 1 6 0 1 0 0
References Study Quality
13 (20809724) 4
109 (27441748) 4
101 (21857034) 3
108 (26204297) 4
107 (19530588) 3
106 (20580503) 3
104 (26376170) 4
103 (28670417) 3
102 (24484060) 2
81 (22194515) 2
110 (23960179) 4
Variant 5: Asymptomatic pathologic spinal fracture with or without edema on MRI.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiation oncology consultation Usually appropriate Strong 3 07 N/A N/A 9 9 0 0 0 0 2 0 4 0 8
References Study Quality
132 (28507888) Inadequate
131 (21277118) 4
134 (25032525) 4
133 (17688054) 2
135 (17224814) 2
93 (21629164) 4
Medical management Usually appropriate Expert Consensus 1 N/A N/A 8 8 1 0 0 1 1 1 2 4 4
Percutaneous vertebral augmentation May be appropriate Strong 3 07 N/A N/A 6 6 0 0 0 1 4 9 0 0 0
References Study Quality
120 (24905395) 4
119 (23816297) 4
118 (22130630) M
117 (8685351) 2
116 (21333599) 1
Percutaneous thermal ablation May be appropriate Strong 3 07 N/A N/A 5 5 0 1 0 0 8 5 0 0 0
References Study Quality
126 (26635286) 2
125 (23265724) 2
124 (24238380) 4
123 (23065947) 2
129 (24927327) 3
128 (14722039) 2
127 (20041484) 2
130 (26022981) 2
122 (26427837) 2
121 (25054391) 3
Surgical consultation May be appropriate (Disagreement) Expert Opinion 2 N/A N/A 5 5 0 0 2 1 5 4 2 0 0
Variant 6: Pathologic spinal fracture with severe and worsening pain.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Radiation oncology consultation Usually appropriate Strong 3 07 N/A N/A 9 9 0 0 0 0 1 2 0 4 7
References Study Quality
131 (21277118) 4
135 (17224814) 2
143 (6178497) 1
Percutaneous vertebral augmentation Usually appropriate Strong 3 07 N/A N/A 7 7 0 0 0 0 4 1 4 4 1
References Study Quality
117 (8685351) 2
137 (28041324) 2
116 (21333599) 1
110 (23960179) 4
14 (24253785) 1
Percutaneous thermal ablation Usually appropriate Strong 3 07 N/A N/A 7 7 0 0 1 1 3 2 6 1 0
References Study Quality
139 (22840806) 3
138 (21170528) 4
126 (26635286) 2
123 (23065947) 2
129 (24927327) 3
128 (14722039) 2
127 (20041484) 2
130 (26022981) 2
122 (26427837) 2
140 (26606009) 2
86 (18566009) 4
121 (25054391) 3
Surgical consultation Usually appropriate Moderate 1 N/A N/A 7 7 0 0 0 0 3 4 3 0 4
References Study Quality
141 (15450879) 4
93 (21629164) 4
142 (16112300) 1
Medical management May be appropriate Moderate 1 N/A N/A 6 6 0 0 0 1 6 2 2 3 0
References Study Quality
136 (12954579) 1
97 (17054286) Not Assessed
95 (22956190) Not Assessed
Systemic radionuclide therapy May be appropriate Limited 3 N/A N/A 5 5 1 0 1 1 7 3 1 0 0
References Study Quality
145 (15925817) 4
144 (15653650) 4
Variant 7: Pathologic spinal fracture with spinal deformity or pulmonary dysfunction.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical consultation Usually appropriate Moderate 1 N/A N/A 8 8 0 0 0 1 1 1 3 3 5
References Study Quality
141 (15450879) 4
11 (21709187) 3
93 (21629164) 4
148 (20562730) 4
142 (16112300) 1
Radiation oncology consultation Usually appropriate Strong 3 07 N/A N/A 8 8 0 0 0 0 4 0 3 4 3
References Study Quality
149 (21533865) 2
119 (23816297) 4
150 (15450875) 4
140 (26606009) 2
143 (6178497) 1
93 (21629164) 4
110 (23960179) 4
Percutaneous vertebral augmentation Usually appropriate Strong 3 07 N/A N/A 7 7 0 0 0 0 4 0 6 2 2
References Study Quality
117 (8685351) 2
79 (18989668) 2
137 (28041324) 2
116 (21333599) 1
81 (22194515) 2
80 (20625321) 2
110 (23960179) 4
14 (24253785) 1
91 (24744201) 3
146 (24935074) 4
24 (26109687) 2
Medical management May be appropriate Expert Consensus 1 N/A N/A 5 5 0 1 0 0 7 4 0 2 0
Percutaneous thermal ablation May be appropriate Strong 3 07 N/A N/A 5 5 0 0 0 1 7 6 0 0 0
References Study Quality
120 (24905395) 4
126 (26635286) 2
108 (26204297) 4
130 (26022981) 2
140 (26606009) 2
86 (18566009) 4
147 (23412159) 2
Variant 8: Pathologic spinal fracture with neurologic deficits.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical consultation Usually appropriate Moderate 3 N/A N/A 9 9 0 0 0 0 0 0 1 1 12
References Study Quality
153 (26337716) Good
152 (-3121235) 4
141 (15450879) 4
11 (21709187) 3
93 (21629164) 4
148 (20562730) 4
Radiation oncology consultation Usually appropriate Strong 3 07 N/A N/A 8 8 0 0 0 0 3 3 0 2 6
References Study Quality
155 (27479724) 4
131 (21277118) 4
154 (7607970) 2
150 (15450875) 4
143 (6178497) 1
Medical management May be appropriate Limited 3 N/A N/A 5 5 0 0 0 1 8 1 1 1 2
References Study Quality
151 (15047923) 4
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.