Population Covered By The Guidance
This pathway provides guidance for imaging patients with bone pain. There are links to other pathways for imaging patients with suspected bony metastases, myeloma, soft tissue masses, low back pain or joint pain in various joints.
Lead Researcher: Charlotte Humphries
Experts & Contributors: Ashley Bennett (images), Eamon Koh, Michael Mason
Editorial Panel: Core membership
Link to Editorial Panel
Date reviewed: August 2013
Date Published: October 2013
- Plain radiography of the symptomatic area is the initial investigation of choice for bone pain or suspected primary bone lesion. Most primary bone tumours are benign, but primary malignant bone tumours are an important cause of cancer morbidity and mortality in young people
- Advanced imaging modalities provide complimentary information to each other
- MRI is generally the advanced imaging modality of choice to further characterise radiograph findings or to further investigate persisting localised symptoms after a normal radiograph
- CT is useful to further define bony anatomy and in suspected osteoid osteoma and bone biopsy guidance
- Nuclear medicine studies are useful in suspected multifocal osseous pathology (e.g. bony metastases, osteomyelitis), metabolic bone disease and inflammatory arthropathy.
- If lesion diagnosis is uncertain and management will be altered, bone biopsy can be considered after review by a musculoskeletal tumour surgeon, taking into account lesion accessibility and patient comorbidities
Date of literature search: June 2013
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- National Institute for Health and Care Excellence (NICE). NICE Clinical Guideline 27: Referral guidelines for suspected cancer. 2005 [updated 2011 April; cited 2013 June 25th]. (Evidence based guidelines). View the guidelines
- Expert Panel on Musculoskeletal Imaging:, Morrison W, Zoga A, Daffner RH, Weissman BN, Bancroft L, et al. ACR Appropriateness Criteria: Primary bone tumours. American College of Radiology; 2009 [cited 2013 April 1]. (Evidence based guideline). View the guideline
- Ludwig H, Kumpan W, Sinzinger H. Radiography and bone scintigraphy in multiple myeloma: a comparative analysis. Br J Radiol. 1982;55(651):173-81. (Level III evidence)
- Dimopoulos M, Terpos E, Comenzo RL, Tosi P, Beksac M, Sezer O, et al. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple Myeloma. Leukemia. 2009;23(9):1545-56. (Evidence based guidelines)
- Frank JA, Ling A, Patronas NJ, Carrasquillo JA, Horvath K, Hickey AM, et al. Detection of malignant bone tumors: MR imaging vs scintigraphy. AJR Am J Roentgenol. 1990;155(5):1043-8. (Level III evidence)
- Hogeboom WR, Hoekstra HJ, Mooyaart EL, Freling NJ, Veth RP, Postma A, et al. MRI or CT in the preoperative diagnosis of bone tumours. Eur J Surg Oncol. 1992;18(1):67-72. (Level II evidence)
- Bloem JL, Taminiau AH, Eulderink F, Hermans J, Pauwels EK. Radiologic staging of primary bone sarcoma: MR imaging, scintigraphy, angiography, and CT correlated with pathologic examination. Radiology. 1988;169(3):805-10. (Level II evidence)
- Yu HHM, Tsai Y-Y, Hoffe S. Overview of diagnosis and management of metastatic disease to bone. Cancer Control. 2012;19(2):84-91. (Review article)
- Ilaslan H, Schils J, Nageotte W, Lietman SA, Sundaram M. Clinical presentation and imaging of bone and soft-tissue sarcomas. Cleve Clin J Med. 2010;77 Suppl 1:S2-7. (Review article)
- Pettersson H, Gillespy T, 3rd, Hamlin DJ, Enneking WF, Springfield DS, Andrew ER, et al. Primary musculoskeletal tumors: examination with MR imaging compared with conventional modalities. Radiology. 1987;164(1):237-41. (Level III evidence)
- Collins MS, Koyama T, Swee RG, Inwards CY. Clear cell chondrosarcoma: radiographic, computed tomographic, and magnetic resonance findings in 34 patients with pathologic correlation. Skeletal Radiol. 2003;32(12):687-94. (Level II evidence)
- Murphey MD, Jelinek JS, Temple HT, Flemming DJ, Gannon FH. Imaging of periosteal osteosarcoma: radiologic-pathologic comparison. Radiology. 2004;233(1):129-38. (Level II/III evidence)
- Littrell LA, Wenger DE, Wold LE, Bertoni F, Unni KK, White LM, et al. Radiographic, CT, and MR imaging features of dedifferentiated chondrosarcomas: a retrospective review of 174 de novo cases. Radiographics. 2004;24(5):1397-409. (Level II/III evidence)
- Murphey MD, wan Jaovisidha S, Temple HT, Gannon FH, Jelinek JS, Malawer MM. Telangiectatic osteosarcoma: radiologic-pathologic comparison. Radiology. 2003;229(2):545-53. (Level III evidence)
- Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J, et al. Osteoid osteoma: MR imaging versus CT. Radiology. 1994;191(1):217-23. (Level III evidence)
- Davies M, Cassar-Pullicino VN, Davies AM, McCall IW, Tyrrell PN. The diagnostic accuracy of MR imaging in osteoid osteoma. Skeletal Radiol. 2002;31(10):559-69. (Level III evidence)
- Zampa V, Bargellini I, Ortori S, Faggioni L, Cioni R, Bartolozzi C. Osteoid osteoma in atypical locations: the added value of dynamic gadolinium-enhanced MR imaging. Eur J Radiol. 2009;71(3):527-35. (Level III evidence)
- Liu PT, Chivers FS, Roberts CC, Schultz CJ, Beauchamp CP. Imaging of osteoid osteoma with dynamic gadolinium-enhanced MR imaging. Radiology. 2003;227(3):691-700. (Level III evidence)
- Niitsu M, Takeda T. Solitary hot spots in the ribs on bone scan: value of thin-section reformatted computed tomography to exclude radiography-negative fractures. J Comput Assist Tomogr. 2003;27(4):469-74. (Level II/III evidence)
- Levine BD, Motamedi K, Chow K, Gold RH, Seeger LL. CT of rib lesions. AJR Am J Roentgenol. 2009;193(1):5-13. (Review article)
- Dalbeth N, Choi HK. Dual-energy computed tomography for gout diagnosis and management. Curr Rheumatol Rep. 2013;15(1):301. (Review article)
- The Royal College of Radiologists. iRefer 7.0.1: Making the best use of clinical radiology. 2012 [updated 2012 Jan; cited 2013 May 5]; 7. (Evidence based guideline). View the guideline
- Schaffer DL, Pendergrass HP. Comparison of enzyme, clinical, radiographic, and radionuclide methods of detecting bone metastases from carcinoma of the prostate. Radiology. 1976;121(2):431-4. (Level III evidence)
- Du Y, Cullum I, Illidge T, Ell P. Fusion of metabolic function and morphology: sequential [18F]fluorodeoxyglucose positron-emission tomography/computed tomography studies yield new insights into the natural history of bone metastases in breast cancer. J Clin Oncol. 2007;25(23):3440-7. (Level II evidence)
- Treglia G, Salsano M, Stefanelli A, Mattoli MV, Giordano A, Bonomo L. Diagnostic accuracy of (1)(8)F-FDG-PET and PET/CT in patients with Ewing sarcoma family tumours: a systematic review and a meta-analysis. Skeletal Radiol. 2012;41(3):249-56. (Level I/II evidence)
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
 |
None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
 |
Medium | 5-10 mSv |
 |
High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
Spotted an error or outdated info? Click to tell us.
Plain Radiography
Plain radiography
Initial imaging modality of choice in patients with bone pain.
- Initial imaging modality of choice for patients with localised bone pain to screen for tumours and tumour-like conditions
- If radiographic features are definitively benign, further imaging may not be necessary unless further anatomic information is required, there is concern of secondary complications (such as pathological fracture) or surgery is contemplated
- If multiple myeloma is suspected a radiographic skeletal survey is more sensitive than bone scintigraphy and still considered the gold standard initial imaging modality to detect osteolytic lesions
- A patient with persistent pain after conservative management should have further imaging despite normal radiographs, as substantial bone mineral content loss has to occur before changes become radiographically apparent
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging
MRI can further evaluate suspicious findings on radiography or other imaging, or persisting pain after normal radiographs.
- MRI can further evaluate indeterminate or potentially malignant findings on radiography or bone scan, providing superior contrast resolution, anatomical detail and assessment of bone marrow and soft tissue involvement
- It is the localised advanced imaging modality of choice for suspected osteomyelitis, primary or secondary bone tumour, occult stress or pathological fracture and soft tissue mass that may be associated with bone pain
- Allows definition of bone tumour size and local intraosseous and extraosseous extent, and is useful in the assessment of tissue characteristics, vascularity and necrosis
- Limitations
- Longer scanning time and respiratory movement artefact mean MRI is not as well suited to depicting the thoracic wall. CT is better suited
- Contraindicated in the presence of a ferromagnetic substance; e.g. pacemaker, aneurysm clip, cochlear implant, ocular foreign body, spinal cord stimulator and some stent materials
Computed Tomography (CT)
Computed tomography
Useful to further define bony anatomy, when MRI is contraindicated or unavailable, in suspected osteoid osteoma chest wall osseous pathology and bone biopsy guidance.
- Alternative if MRI is contraindicated or unavailable
- Superior to MRI in revealing cortical integrity and the extent of structural destruction. , Useful for further evaluation of matrix mineralisation, calcification, cortical or periosteal involvement and pathological fractures ,,
- More accurate than MRI in detecting the characteristic nidus of osteoid osteoma, a benign tumour which usually affects the long bones, particularly the proximal femur and tibial shaft, although the use of dynamic gadolinium-enhanced MRI improves nidus conspicuity compared to CT, especially at atypical sites ,
- Useful for further evaluation of rib pathology after abnormal radiograph or bone scan ,
- Dual energy CT may be used to noninvasively diagnose and monitor gouty tophi or calcium crystal deposits by analysis of the chemical composition of the scanned materials
- Useful in guiding needle biopsy
Bone Scintigraphy
Bone scan
Useful in screening for bone metastases or multiple bone lesions, multifocal infection or when MRI is contraindicated or unavailable.
- Nuclear medicine studies are useful in multifocal osseous pathology (e.g. bony metastases, osteomyelitis), metabolic bone disease and inflammatory arthropathy. Technetium-99 (99mTc) accumulates at sites of elevated bone turnover
- Initial imaging modality of choice in detecting bone metastases, regardless of presence of symptoms
- Advantages
- Allows total body survey
- Sensitive
- Limitations
- Non-specific; radiographic correlation and further anatomic characterisation with MRI or CT is often required
- Some lytic bone metastases may not show increased uptake on bone scan, and are better detected by metabolic scans such as FDG-PET because they have a high glucose metabolism or anatomical assessment with CT or MRI
Positron Emission Tomography (PET)
- Can identify metabolically active skeletal metastases that may or may not have detectable structural destruction
- Its use in staging and follow up evaluation is increasing for a number of malignancies, including Ewing sarcoma family tumours
- However, it is associated with high radiation exposure and cost