Imaging recommendation · Musculoskeletal

Bone pain or elevated alk phos in older adult, suspected Paget disease of bone

Q: What's the alternative imaging for bone pain or elevated alk phos in older adult, suspected paget disease of bone when suspected sarcomatous transformation?

MRI — MRI affected bone + biopsy (iv contrast).

Recommended: Skeletal survey or Tc-99m MDP bone scan + targeted X-rays is the preferred imaging study for bone pain or elevated alk phos in older adult, suspected paget disease of bone. Localized bone remodeling — lytic, mixed, sclerotic phases.

Recommended study

Skeletal survey or Tc-99m MDP bone scan + targeted X-rays

NM IV contrast Preferred Musculoskeletal Outpatient Reviewed 2026-05

Localized bone remodeling — lytic, mixed, sclerotic phases. Pelvis, lumbar spine, femur, skull common.

If the default doesn't apply

Suspected sarcomatous transformation

MRI MRI affected bone + biopsy IV contrast

Watch-outs

Sarcomatous transformation in < 1%

New pain or rapidly enlarging lesion warrants MRI + biopsy.

Fracture risk in long bones

Bone is structurally weakened despite increased density.

Pearls

Cortical thickening + coarsened trabeculae + bone expansion.
'Picture frame' vertebra, 'cotton wool' skull, blade-of-grass lytic front.
Bisphosphonates first-line; preoperative bisphosphonate reduces bleeding.