Purpose: The purpose of this study was to evaluate the differential diagnostic value of 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (¹⁸F-FDG) positron emission tomography (PET)/computed tomography (CT) for benign and malignant vertebral compression fractures (VCFs), where the diagnostic accuracy of ¹⁸F-FDG PET/CT was compared with magnetic resonance imaging (MRI). 
Patients and methods: Between 2015 and 2017, we retrospectively evaluated 87 patients with 116 VCFs. MRI was performed in all the 87 patients, whereas ¹⁸F-FDG PET/CT was executed in 51 patients. Three malignant features (convex posterior cortex, epidural mass formation, and pedicle enhancement) from MRI and the maximum standardized uptake value (SUV_max) from ¹⁸F-FDG PET/CT were evaluated in benign and malignant VCFs, respectively. Sensitivity, specificity, positive predictive value, and negative predictive value of MRI and ¹⁸F-FDG PET/CT were compared in the differentiation of malignant from benign VCFs. 
Results: The results of our investigation showed that the sensitivity and specificity for predicting malignant VCFs were 75.6% and 77.3% for convex posterior cortex, 82.9% and 813% for epidural mass formation, and 85.7% and 70.8% for pedicle enhancement. ¹⁸F-FDG PET/CT demonstrated higher sensitivity (100%) but lower specificity (38.9%) as compared to MRI with regard to differentiation between benign and malignant VCFs. A significant difference in the SUV_max values was observed between the benign and malignant fractures (2.9 ± 1.0 vs 5.0 ± 1.8, P < 0.01). Besides the value of SUV_max, it has been noticed that the FDG uptake pattern differed in malignant and benign fractures. 
Conclusion: Significant MRI findings such as convex posterior cortex, epidural mass formation, and pedicle enhancement are highly suggestive of malignancy. ¹⁸F-FDG PET/CT reliably differentiated the fractures of malignant from benign based on both SUV_max and ¹⁸F-FDG uptake pattern. In a situation where MRI findings are not diagnostic, ¹⁸F-FDG PET/CT provides additional information as it has high sensitivity and is semiquantitative.
Keywords: vertebral compression fractures, MRI, ¹⁸F-FDG PET/CT, maximum standardized uptake value