Emerg Radiol
DOI 10.1007/s10140-016-1460-8
ORIGINAL ARTICLE
Acute traumatic intraosseous fluid sign predisposes to dynamic
fracture mobility
Troy A. Hutchins 1 & Richard H. Wiggins 1 & Jill M. Stein 1 & Lubdha M. Shah 1
Received: 5 September 2016 / Accepted: 24 October 2016
# American Society of Emergency Radiology 2016
Abstract The intraosseous fluid sign (IFS) in chronic os-
teoporotic vertebral fractures is attributed to fluid accumu-
lation within non-healing intervertebral clefts. IFS can also
be seen in acute traumatic fractures, not previously de-
scribed. We hypothesize a pathophysiological mechanism
for the acute traumatic intraosseous fluid sign (ATIFS) and
its predisposition to dynamic fracture mobility with axial
loading on upright radiographs. Retrospective analysis was
performed of 41 acute thoracic and lumbar compression or
stable burst fractures with both supine CT and upright plain
films completed within 1 week of each other. The presence
of an intravertebral cleft with fluid attenuation and verte-
bral body height loss was assessed on CT scans. Changes
in the fractured vertebral body height and angulation were
measured on upright radiographs. The ATIFS was identi-
fied in 18 (44%) of the 41 acute fractures. Mean kyphotic
angle increase was significantly greater (p = 0.000) for
ATIFS fractures (8.2, SD 4.2) than fractures without
ATIFS (1.6, SD 3.4). There was significantly greater
mean anterior (p = 0.0009) and central (p = 0.026) height
loss in ATIFS fractures (4.3 mm, SD 3.76 and 1.89 mm,
SD 4.44, respectively) compared to fractures without
ATIFS (0.59 mm, SD 2.24 and 0.52 mm, SD 2.01,
respectively). The IFS can be seen in acute traumatic ver-
tebral fractures and show dynamic mobility. These ATIFS
fractures show statistically significant greater mean height
loss ratio differences and have significantly greater
* Troy A. Hutchins
troy.hutchins@hsc.utah.edu
1
Department of Radiology, University of Utah Health Sciences
Center, 30 North, 1900 East, #1A071, Salt Lake
City, UT 84132-2140, USA
changes in kyphotic angulation on upright imaging when
compared to fractures without ATIFS.
Keywords Compression fracture . Burst fracture . Vertebral
body . Spine
Introduction
Horizontal linear fluid signal intensity on magnetic resonance
(MRI) within an osteoporotic vertebral fracture is known as
the intraosseous fluid sign (IFS), which represents fluid accu-
mulation within an intravertebral cleft [1]. Such intravertebral
clefts within fractured osteoporotic vertebral bodies have been
well-described [27] and are attributed to avascular necrosis
with incomplete fracture healing [3, 8]. The etiology of fluid
accumulation within an intravertebral cleft has been suggested
to be chronic immobility [8], with movement of fluid into the
cleft through negative pressure [4, 6, 8, 9].
The clinical implications of fluid within an intravertebral
cleft remain under debate [7, 8, 10], with theories attributing
the content of the cleft to the stage or severity of fracture [7,
10]. In patients with unhealed osteoporotic fractures and per-
sistent pain, a fluid sign has been associated with increased
dynamic mobility, higher patient pain scores, and worse per-
formance status [8]. Prior studies have evaluated the fluid sign
in the context of patients with osteoporotic fractures present-
ing for vertebroplasty treatment [5, 11]. These studies have
concluded that those patients with unhealed, painful, mobile
osteoporotic compression fractures preferentially benefit from
vertebroplasty [8].
In acute traumatic fractures, an intervertebral cleft can also
accumulate fluid with the imaging appearance of the IFS,
which has not previously been characterized to our knowl-
edge. The purpose of this study was to determine whether

such acute traumatic intraosseous fluid sign (ATIFS) fractures
are also predisposed to dynamic fracture mobility.
Materials and methods
Subjects
An IRB-approved retrospective query of the radiology infor-
mation system was performed at a level 1 trauma center for the
term Bfracture^ during a 3-year period from March 2009 to
March 2012 for all CT studies of the thoracic or lumbar spine.
Those patients with compression or burst fractures of the tho-
racic or lumbar spine less than 1 week in age based on imaging
and clinical history and those who also had comparison up-
right radiographs performed within 1 week of the CT study
were included. The electronic medical record was reviewed
for each patients history, definitive treatment, and clinical
follow-up. Chronic or indeterminate-age fractures by imaging
and history and severe scoliosis limiting accurate measure-
ments and imaging evaluation were excluded. Vertebral frac-
tures requiring operative treatment for neurologic deficit or
severe osseous deformity [12] were also excluded from our
subject group.
Imagingdefinitions and criteria
All CT imaging was performed on a 64-slice scanner
(Siemens AG, Erlangen, Germany) with helical acquisition
and 0.6 mm collimation. All CT scans were reviewed in the
axial, sagittal, and coronal planes in bone algorithm for the
presence or absence of acute (less than 1 week) fracture, using
features such as cortical disruption, irregular linear lucency
without corticated margins, and height loss.
The fractures were radiographically characterized accord-
ing to the Denis classification of spinal fractures [13], where
compression fractures involve only the anterior column and
burst fractures involve the anterior and middle columns.
Fractures involving the posterior column, including flexion-
distraction and fracture dislocation injuries, were excluded
based on the inherent instability predisposing such injuries
for operative management due to mechanical instability and
associated neurologic compromise. Also, excluded were pa-
tients with imaging features suggestive of disruption of the
posterior ligamentous complex with consequent vertebral col-
umn instability, such as axial compression greater than 50%
and kyphotic angle greater than 25 [12, 14, 15], which may
indicate the need for operative stabilization. Fractures were
then evaluated for the presence or absence of ATIFS on CT,
defined as a linear area of fluid attenuation and disruption/
absence of trabeculation within a vertebral body fracture cleft
[16]. The average Hounsfield unit of the IFS was measured
using a region of interest (ROI) of 0.5 cm2 on the sagittal and
Emerg Radiol
coronal reconstructions, with care to exclude the adjacent
bone. Average Hounsfield units of the L1 vertebral body (or
a non-fractured adjacent vertebral body) was also measured in
all patients with a standard ROI size of 0.5 cm2 on sagittal
reconstructions, in order to quantify bone mineralization
[1719]. All radiographic imaging was performed according
to published standardized protocols, with upright anterior-
posterior and lateral views obtained to include the affected
vertebral body fracture.
Measurement of dynamic mobility
Vertebral body (VB) height and kyphotic angulation were
calculated on supine sagittal CT and upright lateral radio-
graphic images. The radiographic image was calibrated to a
reference normal VB height on the corresponding supine CT.
The anterior, central, and posterior VB heights were measured
to the nearest millimeter for each fracture on both upright
lateral radiograph and supine midline sagittal CT [8, 11].
The mean dynamic height loss difference at each anterior,
central, and posterior location was compared between cases
with or without IFS. Posterior VB height of the adjacent nor-
mal VB was also measured to the nearest millimeter. A height
loss ratio of the minimum fractured vertebral body height
(min) relative to the posterior height of the adjacent normal
(NL) VB was calculated (1[min/NL posterior]) for both up-
right radiograph and supine CT images. A dynamic height loss
ratio difference was then calculated as the supine CT height
loss ratio minus the upright radiograph height loss ratio [20].
Kyphotic angulation was measured from the superior and in-
ferior endplates of the fractured VB on upright and supine
images [21]. The change in kyphotic angle was calculated as
the supine CT angle minus the upright radiograph angle.
Statistical analysis
For group comparisons, categorical variables were compared
using a chi-square test, or Fishers exact test, as appropriate.
For continuous variables, the Students t test was used. All
data was analyzed using two-tailed test and a P value of
<0.05 was considered significant. All statistical analysis was
performed using Stata 14 for Mac (Version 14.0, StataCorp,
College Station, TX).
Results
The RIS query for Bfracture^ of the thoracic or lumbar spine
yielded 193 CT exams. Twenty-eight trauma patients (15
males, 13 females) (age range 1595 years, mean 55.07 (SD
23.02)) meeting the inclusion criteria were found to have 41
acute thoracic or lumbar vertebral fractures. Seventeen (41%)
thoracic and 24 (59%) lumbar spine fractures were identified.
Emerg Radiol
Table 1 Demographics of
trauma patients with spine
fractures. There were 41 fractures
in 28 patients Total fractures
Age (mean, range) (year)
Gender
Osteoporosis present
(HU 135)
Fracture level (number)
Fracture type
Treatment
Of the 41 fractures, 25 (61%) were classified as compression-
type and 16 (39%) as burst-type. Underlying marrow pathol-
ogy was evident in five patients with 12 (29%) vertebral frac-
tures, of which five had ATIFS (Table 1).
The ATIFS was identified on CT in 18 (44%) fractures and
was more common in burst-type fractures (69%) compared to
compression-type fractures (28%) (p = 0.010) (Fig. 1). There
were 23 (56%) vertebral fractures without ATIFS (Fig. 2).
The Hounsfield unit measured in the L1 VB (or adjacent
non-fractured VB) ranged 51 to 416 with mean 189.7 HU, SD
96.6 [18]. Although this includes the five patients with the 12
pathologic fractures, there was also no significant difference
in the bone densities of those patients with ATIFS fractures
and those without the imaging finding (p = 0.465). There was
no significant difference between the CT and radiographic
measurements of the posterior height of a normal adjacent
VB (mean difference 0.0317 mm, SD 0.378).
Those vertebral fractures with ATIFS had significantly
greater dynamic anterior (p = 0.0009) and central
(p = 0.026) height loss on upright imaging relative to supine
imaging. Mean anterior height loss was 4.3 mm (SD 3.76)
for ATIFS fractures, compared to 0.59 mm (SD 2.24) for
fractures without ATIFS. Similarly, mean central height loss
was 1.89 mm (SD 4.44) for ATIFS fractures, and mean
0.52 mm (SD 2.01) for fractures without ATIFS. The pos-
terior VB dynamic height loss was not significantly different
in fractures with or without ATIFS (p = 0.8514); mean height
loss was 0.18 mm (SD 2.11) for ATIFS fractures and
0.30 mm (SD 2.02) without ATIFS (Table 2). There was a
statistically significant greater dynamic mean height loss ratio
difference in ATIFS fractures (p = 0.021), which was best
demonstrated on upright radiographs as compared to supine
imaging (p = 0.0095) (Table 3).
Baseline mean kyphotic angle for all fractures was 6.2 (SD
7.6) degrees on supine CT and 10.7 (SD 7.2) degrees on
upright radiographs. The dynamic change in kyphotic angle
was greater in ATIFS fractures (p = 0.000). On upright relative
to supine imaging, the mean increase in kyphotic angle for
IFS present IFS absent
18 23
61.2 (2795) 49.7 (1578)
12 female, 6 male 8 female, 15 male
202.4 SD130.3 179.8 SD+60.1
L1(6) L2,L3,T11(2) L1(6) L2,L4(3) T6,T10,T12(2)
T7,T8,T10,T12,L4,L5(1) T1,T4,T7,T8,T11(1)
Compression (7), burst (11) Compression (18), burst (5)
Conservative only (7), +brace (9), Conservative only (5), +brace
+brace (1), kyphoplasty(1) (16), +brace (1)
ATIFS fractures was 8.2 (SD 4.2) and 1.6 (SD 3.4) in
fractures without ATIFS.
Imaging and clinical follow-up
Twenty-six fractures had imaging follow-up for up
to18 months, 11 of which were unchanged. Fifteen frac-
tures (58%) displayed mild interim in height loss.
Twenty-seven of the fractures had clinical follow-up, 18
(67%) of which were correlated with decreased pain. Of
these 18 fractures, only 4 fractures (22%) displayed
ATIFS. There was significant correlation between pain
and ATIFS in our trauma population (p = 0.04) at up to
12 months clinical follow-up. All of these fractures were
treated non-operatively, with the exception of two fractures
in one elderly patient who underwent kyphoplasty for per-
sistent pain. Notably, this patient had low bone mineral
Fig. 1 a Sagittal CT reconstruction of the lumbar spine, obtained with the
patient in supine position, demonstrates a two-column fracture of the L3
vertebral body with an intraosseous fluid sign (arrow). The height of the
vertebral body is minimally decreased in comparison to the adjacent
normal vertebral levels on this image. b Sagittal STIR image with the
same patient in supine position shows hyperintense signal throughout the
L3 vertebral body marrow in keeping with edema. Focal fluid signal is
noted in the intravertebral cleft (arrow),corresponding the low attenuating
collection on the CT. c Upright lateral radiograph reveals significant
height loss of the L3 vertebral body as compared to the supine imaging
modalities (arrow). The upright axial loading has compressed the
serosanguineous fluid in the posttraumatic intravertebral cleft with
consequent dynamic fracture mobility

Fig. 2 a Sagittal CT reconstruction of the lumbar spine, obtained with the
patient in supine position, demonstrates an anterior column compression
fracture of the L1 vertebral body without intravertebral fluid attenuation
to suggest an intraosseous fluid sign (arrow). b Lateral upright radiograph
shows preservation of the L1 vertebral body height (arrow) and no
dynamic fracture mobility with axial loading related to upright
positioning
density and two ATIFS fractures; one of which also
displayed gas and therefore was compatible with an acute
on chronic fracture. In this patient, the dynamic vertebral
height loss ratio measured 20.5% with 10 angulation.
Seven of the 27 fractures (26%) had confounding sources
of back pain, which were not directly attributable to the
fracture by clinical assessment.
Discussion
The trauma population with acute vertebral fractures in our
study is distinct from the population of unhealed osteoporotic
vertebral fractures with intraosseous fluid sign reported previ-
ously [5, 8, 11]. In our patient cohort with acute compression
or burst fractures, 44% had acute traumatic intraosseous fluid
sign (ATIFS). Patients with ATIFS fractures showed statisti-
cally significant greater mean height loss ratio difference and
significantly greater increased kyphotic angulation on upright
imaging compared to fractures without ATIFS. There was no
significant difference in bone mineral density between ATIFS
and non-ATIFS fractures. The ATIFS in our patients was more
common in burst fractures, in keeping with the findings of
Table 2 Mean, standard
deviation (SD), and range for the
anterior, central, and posterior
vertebral body (VB) heights (all
fractures grouped), and the Anterior
posterior height of a normal Center
adjacent VB, on upright and
supine images Posterior
Posterior normal VB
Emerg Radiol
Baur et al., who demonstrated that the fluid sign is correlated
with an increased severity of vertebral body fracture [1]. As in
our cases, it was also observed that a fluid sign occurs where
there is the most severe compression of the spongiosa at the
fractured endplate [1].
Previous studies of the IFS are in the context of subacute to
chronic osteoporotic compression fractures with fluid accu-
mulating within a non-healing cleft. In our patient population
in the setting of acute trauma, however, there is no preexisting
cleft within the vertebral body to account for the fluid accu-
mulation. Therefore, the fluid-filled cleft is thought to occur at
the time of the injury. We hypothesize a traumatic mechanism
of axial compression and flexion followed by equal or greater
hyperextension. During flexion/compression, the vertebral
body fractures and loses height. The fracture results in weak-
ened medullary bone near the vertebral endplate with a hori-
zontal linear band of impacted trabeculae; this is in keeping
with the proposed mechanism by Baur et al [1]. The anterior
longitudinal ligament adjacent to this zone of impacted bone
buckles anteriorly. In our proposed mechanism, there is sub-
sequent hyperextension with a slight distraction component,
during which the weakened linear band of fractured bone sep-
arates as the vertebral body regains some of its original height
and the anterior longitudinal ligament pulls taut but does not
rupture. This creates a horizontal linear cavity that then fills
with fluid and/or hemorrhage, seen on imaging as the ATIFS
(Fig. 3). The distraction component allows the serosanguinous
fluid to fill the cleft between the disrupted trabeculae. A pre-
dominant compression mechanism only would allow edema
to disperse into the marrow [22].
Studies have shown that there is some degree of Bsettling^
and increasing kyphotic angulation over time with simple
compression fractures or stable burst fractures and that this
does not correlate with pain [23]. Similarly, greater than half
of the fractures with imaging follow-up in our series showed
mild progression of height loss without associated pain. An
increase in fracture kyphotic angle greater than 10 on upright
relative to supine positioning has been suggested as an indi-
cation for operative intervention [24]. While the ATIFS was
associated with greater vertebral height loss and angulation
compared to those fractures without the ATIFS in our patients,
the mean increased angulation in ATIFS fractures was less
than this aforementioned 10-degree threshold. The dynamic
Supine Upright
(mm mean, SD, and range) (mm mean, SD, and range)
21.15.7 (5.530.9) 18.95.7 (7.733.2)
17.94.4 (8.325.3) 17.45.2 (5.626.7)
25.34.3 (14.833.3) 25.04.8 (14.535.8)
26.34.4 (18.733.9) 26.34.2 (18.433.5)
Emerg Radiol
Table 3 Height loss on supine
and upright imaging and dynamic
height loss
Ratio min/normal
Ratio min/normal with IFS
Ratio min/normal without IFS
Dynamic mean height loss ratio difference with IFS
Dynamic mean height loss ratio difference without IFS
mobility of the ATIFS fracture with upright imaging can be
predicted, and our results show that it not a sign of progression
or instability.
The observation that the IFS correlates with increased dy-
namic mobility in the setting of traumatic fractures is consis-
tent with prior observations that osteoporotic fractures with
intravertebral clefts display abnormal mobility in patients pre-
senting for vertebroplasty [5, 8, 14]. Dynamic mobility has
been attributed to increased pain and decreased performance
status in prior investigations [8]. We found a significant asso-
ciation between the ATIFS and persistent pain on follow-up.
Studies have concluded that those patients with unhealed,
painful, mobile osteoporotic fractures preferentially benefit
from vertebroplasty [8]. The patient with two ATIFS fractures
and persistent pain shared similar demographics with those
patients shown to benefit from percutaneous cement augmen-
tation [14, 15].
Whether acute or chronic, the IFS represents a fluid-
filled horizontal linear intraosseous cavity. Therefore,
ATIFS and osteoporotic IFS will behave similarly and
Fig. 3 Graphic images above and representative CT images below for
hypothesized ATIFS mechanism. Normal vertebral body (a, e). With
flexion-compression, there is vertebral body fracture and loss of height
with linear band of impacted trabeculae (b, f) and buckling of the anterior
longitudinal ligament (yellow arrow). With subsequent hyperextension,
the weakened fractured bone separates while the anterior longitudinal
ligament pulls taut, creating a horizontal linear cavity that then fills with
fluid and/or hemorrhage (c, g)
Supine Upright
mean, SD, (95% CI) mean, SD, (95% CI)
0.330.15 (0.290.38) 0.370.16 (0.320.42)
0.350.17 (0.270.43) 0.440.17 (0.350.53)
0.320.13 (0.260.38) 0.310.13 (0.250.37)
0.910.18
0.100.90
show a loss of height when imaging is performed with
weight-bearing. However, when an acute fracture occurs,
the bone surrounding the intraosseous cavity is more likely
to be viable relative to the bone surrounding a chronic frac-
ture with a non-healing IFS cleft. It is therefore possible
that despite the similar appearances, ATIFS fractures may
behave differently than IFS fractures with respect to subse-
quent healing and pain on follow-up. The majority of our
patients with clinical follow-up (67%) had decreased or
resolved pain attributable to the fracture. This may be due
to differences in the pathophysiology of the IFS in acute
traumatic fractures as opposed to unhealed osteoporotic
fractures. The clinical medical record was the reference
for determining the improvement or persistence of pain,
particularly whether it was directly attributable to the trau-
matic fracture(s). Given the multifactorial causes of back
pain, this can be challenging to filter.
Although a few of our patients had underlying marrow
pathology, which may introduce heterogeneity in the imaging
appearance of the ATIFS, there was no significant difference
in bone densities of those patients with ATIFS and those with-
out the imaging finding (p = 0.465). Tumor cell-filled marrow
reportedly makes IFS rare in malignant fractures (6% of neo-
plastic fractures in the study by Baur et al. [1]). However, it is
important to be aware that IFS is not a definitive imaging sign
of benignity. In our two patients (five ATIFS fractures) with
underlying bone marrow pathology, the traumatic etiology of
the fractures may have contributed to the greater percentage of
ATIFS (42%). Marrow abnormality, whether due to osteopo-
rosis or tumor, can weaken the vertebral column with vulner-
ability to fracture, which can demonstrate ATIFS.
An important point to consider in our methodology is
the use of the dynamic height loss ratio as it allowed for
an internal comparison. A direct comparison of values
by different modalities (i.e., supine CT and upright ra-
diographs) is limited given issues with magnification,
parallax, etc. This is reflected by the absolute numbers
that were measured for anterior, central, and posterior
height loss on supine CT versus upright radiograph im-
ages, some of which were negative values. For example,
the mean Bincreased^ height in the center of the vertebral
body with upright positioning as compared to the supine
positioning for fractures without ATIFS (0.52 mm, SD

2.01) is thought to be due to parallax. A more accurate
delineation of the cortical margins is possible on CT.
Although there was no significant difference between
the CT and radiographic measurements of the posterior
height of a normal adjacent vertebral body, the center of
the fractured vertebral body may have been positioned
caudal to the x-ray beam center, with relative beam di-
vergence distorting radiographic landmarks. This paral-
lax effect may contribute to the difficulty determining
the cortical margin of the center of the fractured verte-
bral body. This was less problematic for the anterior and
posterior margins. Of note, the parallax can be exagger-
ated in large patients [25].
Little is known about the evolution of ATIFS on im-
aging, but as stated earlier, the IFS is evident in subacute
and chronic osteoporotic fractures. Although the major-
ity of upright imaging was performed within 12 days of
the trauma (four patients with eight fractures had upright
radiographics greater than 1 day but within 1 week), the
clinical scenario (e.g., pain, co-morbidities, transfer
from outside institution, etc.) determined the timing of
the upright radiographs. Bone marrow edema in vertebral
compression fractures on MRI, which is more sensitive
than CT, resolves after 13 months [26] but can persist
for longer than 3 months [27]. Therefore, it may be hy-
pothesized that the marrow edema and fluid within the
intravertebral cleft would be present at least 1 week. MRI
can be helpful in detecting the IFS, and although MRI
examinations were available in 14 fractures, we did not
choose to include that imaging modality in this study. At
our institution as at many others, MRI is reserved for
those patients with concern for neurological injury or
those that have additional imaging findings suggestive
of mechanical instability. MRI has a role in the detection
of ligamentous injury, modifying the fracture classifica-
tion and therefore treatment approach [28]. However,
recent literature is controversial regarding the utility of
MRI in the acute trauma setting with less sensitivity and
specificity for the integrity of the posterior ligamentous
complex than previously reported [23] and marrow ede-
ma [22, 29]. As CT is the standard for evaluation of acute
spine trauma, the focus of this study is on the more com-
monly encountered manifestation of ATIFS on CT and
radiographs. Further investigations will be helpful to
evaluate the sensitivity of MRI for detection of ATIFS
in comparison to CT.
A recognized limitation of this study is the relatively
small sample size of fractures from a single institution
with limited clinical follow-up in some patients, as is
common in the trauma population. Future studies are
necessary to determine the clinical significance of the
ATIFS with respect to fracture healing, pain on follow-
up, and optimal treatment.
Emerg Radiol
Conclusion
The ATIFS was observed in just under half of the acute
traumatic vertebral fractures in our study. It was associated
with both statistically significant dynamic vertebral body
height loss and increased angulation, paralleling findings
previously described in IFS osteoporotic fractures. It is
important to recognize that the dynamic changes of
ATIFS fractures on upright imaging are expected and
should not be misinterpreted as indicating fracture progres-
sion or instability. The mechanism of these ATIFS fractures
may be distinct from the osteoporotic fractures with IFS
and dynamic mobility. Future studies are necessary to de-
termine the clinical significance of the ATIFS with respect
to fracture healing, pain on follow-up, and optimal
treatment.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
References
1. Baur A, Stabler A, Arbogast S, Duerr HR, Bartl R, Reiser
M (2002) Acute osteoporotic and neoplastic vertebral com-
pression fractures: fluid sign at MR imaging. Radiology
225(3):730735. doi:10.1148/radiol.2253011413
2. Bhalla S, Reinus WR (1998) The linear intravertebral vacuum: a
sign of benign vertebral collapse. AJR Am J Roentgenol 170(6):
15631569. doi:10.2214/ajr.170.6.9609175
3. Dupuy DE, Palmer WE, Rosenthal DI (1996) Vertebral fluid col-
lection associated with vertebral collapse. AJR Am J Roentgenol
167(6):15351538. doi:10.2214/ajr.167.6.8956592
4. Malghem J, Maldague B, Labaisse MA, Dooms G, Duprez T,
Devogelaer JP, Vande Berg B (1993) Intravertebral vacuum cleft:
changes in content after supine positioning. Radiology 187(2):483
487. doi:10.1148/radiology.187.2.8475295
5. Mirovsky Y, Anekstein Y, Shalmon E, Peer A (2005) Vacuum clefts
of the vertebral bodies. AJNR Am J Neuroradiol 26(7):16341640
6. Sarli M, Perez Manghi FC, Gallo R, Zanchetta JR (2005) The
vacuum cleft sign: an uncommon radiological sign. Osteoporosis
international: a journal established as result of cooperation between
the European Foundation for Osteoporosis and the National
Osteoporosis Foundation of the USA 16(10):12101214.
doi:10.1007/s00198-005-1833-4
7. Yu CW, Hsu CY, Shih TT, Chen BB, Fu CJ (2007) Vertebral
osteonecrosis: MR imaging findings and related changes on adja-
cent levels. AJNR Am J Neuroradiol 28(1):4247
8. Kawaguchi S, Horigome K, Yajima H, Oda T, Kii Y, Ida K,
Yoshimoto M, Iba K, Takebayashi T, Yamashita T (2010)
Symptomatic relevance of intravertebral cleft in patients with oste-
oporotic vertebral fracture. J Neurosurg Spine 13(2):267275.
doi:10.3171/2010.3.SPINE09364
9. Linn J, Birkenmaier C, Hoffmann RT, Reiser M, Baur-Melnyk A
(2009) The intravertebral cleft in acute osteoporotic fractures: fluid
in magnetic resonance imaging-vacuum in computed tomography?
Spine 34(2):E88E93. doi:10.1097/BRS.0b013e318193ca06
Emerg Radiol
10. Jang JS, Kim DY, Lee SH (2003) Efficacy of percutaneous
vertebroplasty in the treatment of intravertebral pseudarthrosis as-
sociated with noninfected avascular necrosis of the vertebral body.
Spine 28(14):15881592
11. McKiernan F, Faciszewski T (2003) Intravertebral clefts in osteo-
porotic vertebral compression fractures. Arthritis Rheum 48(5):
14141419. doi:10.1002/art.10984
12. Alexandru D, So W (2012) Evaluation and management of verte-
bral compression fractures. Permanente J 16(4):4651
13. Denis F (1983) The three column spine and its significance in the
classification of acute thoracolumbar spinal injuries. Spine 8(8):
817831
14. Wood KB, Li W, Lebl DS, Ploumis A (2014) Management of
thoracolumbar spine fractures. Spine J: Off J North Am Spine
Soc 14(1):145164. doi:10.1016/j.spinee.2012.10.041
15. Ghobrial GM, Jallo J (2013) Thoracolumbar spine trauma: review
of the evidence. J Neurosurg Sci 57(2):115122
16. Wiggins MC, Sehizadeh M, Pilgram TK, Gilula LA (2007)
Importance of intravertebral fracture clefts in vertebroplasty
outcome. AJR Am J Roentgenol 188(3):634640.
doi:10.2214/AJR.06.0542
17. Pickhardt PJ, Pooler BD, Lauder T, del Rio AM, Bruce RJ,
Binkley N (2013) Opportunistic screening for osteoporosis
using abdominal computed tomography scans obtained for
other indications. Ann Intern Med 158(8):588595.
doi:10.7326/0003-4819-158-8-201304160-00003
18. Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG
(2011) Hounsfield units for assessing bone mineral density and
strength: a tool for osteoporosis management. J Bone Joint Surg
Am 93(11):10571063. doi:10.2106/JBJS.J.00160
19. Schreiber JJ, Anderson PA, Hsu WK (2014) Use of computed to-
mography for assessing bone mineral density. Neurosurg Focus
37(1):E4. doi:10.3171/2014.5.FOCUS1483
20. Teng MM, Wei CJ, Wei LC, Luo CB, Lirng JF, Chang FC, Liu CL,
Chang CY (2003) Kyphosis correction and height restoration ef-
fects of percutaneous vertebroplasty. AJNR Am J Neuroradiol
24(9):18931900
21. Alanay A, Pekmezci M, Karaeminogullari O, Acaroglu E,
Yazici M, Cil A, Pijnenburg B, Genc Y, Oner FC (2007)
Radiographic measurement of the sagittal plane deformity
in patients with osteoporotic spinal fractures evaluation of
intrinsic error. Eur Spine J: Off Publ Eur Spine Soc Eur
Spinal Deformity Soc Eur Section Cervical Spine Res Soc
16(12):21262132. doi:10.1007/s00586-007-0474-z
22. Brinckman MA, Chau C, Ross JS (2015) Marrow edema variability
in acute spine fractures. Spine J: Off J North Am Spine Soc 15(3):
454460. doi:10.1016/j.spinee.2014.09.032
23. Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest
V (2003) Operative compared with nonoperative treatment of a
thoracolumbar burst fracture without neurological deficit. A pro-
spective, randomized study. J Bone Joint Surg Am 85-A(5):773
781
24. Mehta JS, Reed MR, McVie JL, Sanderson PL (2004) Weight-
bearing radiographs in thoracolumbar fractures: do they influence
management? Spine 29(5):564567
25. Auerbach JD, Namdari S, Milby AH, White AP, Reddy SC, Lonner
BS, Balderston RA (2008) The parallax effect in the evaluation of
range of motion in lumbar total disc replacement. SAS J 2(4):184
188. doi:10.1016/SASJ-2008-0020-RR
26. Baker LL, Goodman SB, Perkash I, Lane B, Enzmann DR
(1990) Benign versus pathologic compression fractures of
vertebral bodies: assessment with conventional spin-echo,
chemical-shift, and STIR MR imaging. Radiology 174(2):
495502. doi:10.1148/radiology.174.2.2296658
27. Voormolen MH, van Rooij WJ, van der Graaf Y, Lohle PN,
Lampmann LE, Juttmann JR, Sluzewski M (2006) Bone marrow
edema in osteoporotic vertebral compression fractures after percu-
taneous vertebroplasty and relation with clinical outcome. AJNR
Am J Neuroradiol 27(5):983988
28. Winklhofer S, Thekkumthala-Sommer M, Schmidt D, Rufibach K,
Werner CM, Wanner GA, Alkadhi H, Hodler J, Andreisek G (2013)
Magnetic resonance imaging frequently changes classification of
acute traumatic thoracolumbar spine injuries. Skelet Radiol 42(6):
779786. doi:10.1007/s00256-012-1551-x
29. Lensing FD, Bisson EF, Wiggins RH 3rd, Shah LM (2014)
Reliability of the STIR sequence for acute type II odontoid frac-
tures. AJNR Am J Neuroradiol 35(8):16421646. doi:10.3174/ajnr.
A3962