Osteoporotic vs. Malignant Pathological Spinal Fracture

The key differentiator is DWI signal:

• Osteoporotic fracture → DWI hypointense (normal diffusion, edema only)

• Malignant fracture → DWI hyperintense (restricted diffusion from packed tumor cells)

Additional red flags for malignancy: soft tissue mass, focal marrow replacement, extraosseous extension, mixed osteolysis-sclerosis, and distant lesions.

⚠️ Caveat: Sclerotic metastases and post-radiotherapy lesions cause false-negative DWI — always correlate with ADC values and morphology in equivocal cases.