• 69yo M presents with severe neck pain and head tilt. Underwent imaging that revealed multiple osteolytic lesions throughout spine and pelvis.
    • PMH – Hypertension

    Physical Exam

    • Pt with obvious head tilt on exam
    • CN – intact
    • Motor – 5/5 x 4
    • Sensory – intact
    • DTR – symmetric
    • Cerebellar – normal
    • Gait - normal

    Figure 1. Imaging reveals osteolytic lesion Right C1 and C2

    Figure 2.

    1. Further workup should include the following except:

    2. All of the following cancers commonly metastasize to bone except:

    3. Common presentation of bony metastases include all of the following except:

    4. The patient was placed on a bisphosphonate. What would be your next step in management:

    5. Which of the following describes you?

     6. I practice in one of the following locations.

    7. Please add any suggestions or comments regarding this case:

    • Answer to 4 can vary acording to complementary studies´ findings.
    • is clear no comments tks
    • Like to be challenged and tested
    • Good case
    • Radiosensitivity of primary tumor would help guide whether radiation alone or tumor resection / debulking along with fusion, followed by radiation would be necessary.
    • Flex/Ext would not be pursued if the patient was unable to move head actively (vs. passive movement).
    • Although the biopsy results are not provided, it is assumed from the scenario starting bisophosphonates that this was metastatic breast (although less common in men). Recent trials have shown bisphosphonates can reduce future pathologic fracture and even maybe need for surgery, although this requires survival to 2 years to see benefit. If neck pain improves, can give neoadjuvant radiation (MRI shows the mass not touching cord), and supplement with OC fusion (given progression to condyle, C1 and C2) if progressive instability develops.
    • given the CT and MRI findings, the lateral mass of C1 is affected and the whole right atlanto-occipital region sparing the endplates of the joint, the patients age,then this refers to neoplastic process with more suspicion. So, further spinal axis involvement will point towards multiple myeloma or metastatic lesions. This is mostly treated with radiotherapy/chemotherapy without the need for proper surgical fusion and/or en bloc resection. If the spinal axis is negative, then, en bloc resection and proper fusion is the more likely option.
    • intresting case,needs some detals of previous illness,lab investigations.
    • When reviewing prior cases, the results are beneficial to look at. However, the answer choices are cut off and cannot be read completely which diminishes the learning postential. Could the full choice be printed and not cutoff?
    • Thanks
    • thanx
    • comments
    • i think MRI is also mandatory in this case,to rule out the condition of spinal cord and extend of lesion. meanwhile there is OA and osteophyte at C5-C6 i think he might have syrinx or spinal cord lesion.
    • I would like to do further investigations for a primary and also rule out other metastatic lesions before deciding on definite treatment
    • I would perform posterior occipitocervical fusion to address occipitocervical instability and during this procedure biopsy lesion in in c2 pars/lateral mass for diagnosis. I don't think attempt at en bloc resection is indicated given the presence of other lesions in spine and pelvis (according to information in vignette)
    • Management will be influenced by Biology of Primary. Question 4 may not be appropriate.

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