Abstract: Objective: To explore the value of dual-energy CT virtual monoenergetic imaging in the differential diagnosis of acute and chronic spinal compression fractures. Methods: A total of 85 patients with spinal compression fractures were underwent DECT examination and retrospective analyzed, including 50 acute spinal compression fractures(60 vertebral bodies) and 35 chronic spinal compression fractures(48 vertebral bodies). All lesions were diagnosed by surgical pathology or clinical follow-up. The dual-energy CT virtual monoenergetic images were reconstructed into 9 groups(40~120 ke V). Two radiologists scored the image quality of the dual energy CT virtual monoenergetic imaging at different energy levels. Kappa test was used to evaluate the consistency between observers. A senior radiologist measured the CT values of spinal vertebral bodies with acute and chronic compression fractures under different energy levels of dual-energy CT virtual monoenergetic imaging. The Mann-Whitney U test was used to compare the differences between CT values. The ROC curve was used to analyze the differential diagnostic performance of virtual monoenergetic imaging for acute and chronic spinal compression fractures. Results: The subjective assessment of image quality between the two observers was consistent(Kappa = 0.805), and the image quality score was highest at 80 ke V virtual monoenergetic level. There were statistically significant differences in CT values between spinal acute and chronic vertebral bodies at different levels of virtual monoenergetic imaging, with P values < 0.05. ROC curve analysis showed that the highest AUC value at 120 ke V was 0.72, and the corresponding sensitivity was 86.7%. Conclusion: Compared with conventional CT, dual-energy virtual single-energy imaging can perform qualitative and quantitative comprehensive evaluation through morphological features and CT values. It can better identify acute and chronic compression fractures of the spine, which can help guide clinical treatment decisions and improve patient prognosis.