The 72-Year-Old with Back Pain and a Lytic Vertebral Lesion

Differential:

• Metastatic disease is the most likely cause of a lytic vertebral lesion in a 72-year-old smoker - lung, prostate, kidney, thyroid and breast are the common primaries.
• Multiple myeloma - a lytic lesion with no sclerosis and a history of night pain is classic; check serum electrophoresis, free light chains and urinary Bence-Jones protein.
• Primary bone tumour is less likely at this age but include chondrosarcoma, lymphoma and solitary plasmacytoma.
• Infection (discitis/osteomyelitis) is possible but usually involves the disc and adjacent endplates, and he is afebrile.
• Osteoporotic fracture can cause loss of height, but a purely lytic lesion is not typical.

Imaging:

• MRI of the whole spine (sagittal T1, STIR, and axial sequences through the lesion, with contrast if tolerated) is the single best test: it assesses the extent of marrow replacement, cord or cauda equina compression, and other levels.
• CT of the chest, abdomen and pelvis for a primary and staging.
• Bone scan or PET-CT for skeletal survey and to identify the primary.
• Serum and urine protein electrophoresis, free light chains, calcium and PSA as blood tests to support the diagnosis.

The decision hinges on whether there is cord or cauda equina compression, which is a neurological emergency, versus a stable lytic lesion that can be imaged as an inpatient within 24–48 hours.

Arguments for urgent (same-night) MRI:

• Thoracic back pain with a lytic vertebral body and loss of height carries a real risk of pathological fracture and cord compression, which can progress rapidly.
• If there is any suggestion of neurological symptoms - leg weakness, sensory level, bladder or bowel dysfunction, gait disturbance - this is an emergency and MRI must be done immediately, with neurosurgical and oncology input.
• The examination is documented as normal, but a normal exam does not exclude early cord compression, and the patient is in a high-risk group.

Arguments for an inpatient scan within 24 hours:

• He is neurologically intact, so there is no immediate surgical emergency.
• A whole-spine MRI with contrast takes time and should be protocoled properly; a rushed, limited scan may miss other levels.
• The scan should be performed where the reporting radiologist can review it with the clinical team.

My advice: Arrange an inpatient MRI within 24 hours, with clear instructions to the nursing staff to escalate immediately if any neurological symptom develops, in which case the scan becomes an emergency. Do not send him home for an outpatient scan.

This is metastatic spinal disease with epidural extension but no cord signal change, so it is not yet a surgical emergency, but it is urgent.

• Urgent oncology and neurosurgery/spinal surgery referral. The presence of epidural soft tissue with cord contact means a small further increase in size could cause cord compression. The patient should be admitted and monitored neurologically.
• Steroids: high-dose dexamethasone is often started for epidural disease, but the decision should be made by the oncology team; it is not automatic for asymptomatic cord contact.
• Analgesia and bracing: optimise pain control and consider a spinal brace if there is instability.
• Tissue diagnosis: a CT-guided biopsy of the vertebral lesion or another accessible site is needed to confirm the primary and guide treatment.
• Staging: CT chest/abdomen/pelvis and a full skeletal survey or PET-CT to identify the primary and other sites.
• Radiotherapy vs surgery: if the patient develops neurological deficit, surgical decompression and stabilisation may be indicated; otherwise, palliative radiotherapy to the affected level is often appropriate.
• Document and communicate the plan with the patient and family, including the risk of cord compression and the symptoms that should trigger an emergency call.