Plain radiography of the skull after investigation for raised calcium
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2759 (Published 19 May 2016) Cite this as: BMJ 2016;353:i2759
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Looking at the skull radiograph showed the characteristic features of Paget's disease of the bone. Author thinks that bisphosphonates might be a line of treatment for this patient ! Examining the skull base of this patient showed massive, diffuse ossification ! It means that the cranial foraminae and the foramen magnum are at high risk of obliteration. Giving anti-resorptive agents might lead to the development of progressive obliteration ( potential for new bone re-deposition). The most common complications of progressive cranial base hyperostosis are hearing loss , headache, exophthalmos , and also vision changes, and symptomatic brainstem compression. And the possibility of foramen magnum syndrome. Strikingly, in some cases the hypersotosis extends to involve C1-2, in this case it leads to diffuse bony ankylosis (atlanto-axial). Ankylosed segments are prone to develop osteoporosis of these segments, causing effectively fracture of C1-2 and sudden death. Decompression surgery is not an easy option, since dealing with a thick sclerotic bone which has been already lost its anatomical landmarks is a real risk and challenge. Therefore, prescribing anti-resorptive agents without proper assessment of the skull base , C1-2 is highly hazardous.
Competing interests: No competing interests
Re: Plain radiography of the skull after investigation for raised calcium
We briefly mentioned bisphosphonates as a potential treatment for Paget's disease. As you will know, these agents are used for metabolically active disease, for pain, pre joint replacement, cases of hypercalcaemia/hypercalciuria/renal stones and sometimes in younger patients with raised alk phos - amongst other indications. There are potential contra-indications also, which you allude to. The article we wrote was by its nature short and we only had a few words to cover drug treatments, but thank you for your comments.
Competing interests: No competing interests