What further workup is needed for an elderly female patient with a history of a fall, incidental finding of spinal lesions at T1, T3, T6, and one lumbar (L) vertebra on MRI, with no neurological symptoms, to rule out intraosseous hemangiomas?

Workup for Incidental Spinal Lesions in Elderly Patient with Myelodysplastic Syndrome

This patient requires CT of the spine without contrast as the immediate next step to characterize the bone architecture of these lesions, followed by laboratory workup for multiple myeloma and metastatic disease. 1, 2

Immediate Imaging Workup

CT Spine Without Contrast (First-Line)

• CT is the gold standard for characterizing lytic bone lesions with >98% sensitivity, detecting cortical destruction, trabecular patterns, and fracture risk that are critical for distinguishing hemangiomas from malignant processes 1, 2
• CT provides superior detail of the "polka-dot" or "corduroy" appearance characteristic of vertebral hemangiomas—coarsened vertical trabeculae that are pathognomonic for these benign lesions 3
• Order CT without contrast first to assess matrix mineralization and bone architecture; contrast obscures subtle osseous details and is unnecessary for initial characterization 1

MRI Spine With and Without Contrast (Second-Line)

• MRI with contrast must follow CT to evaluate for epidural extension, spinal cord compression, and soft tissue involvement—complications that would require urgent intervention even in asymptomatic patients 1, 2
• MRI distinguishes "aggressive" hemangiomas (which extend beyond vertebral body into epidural space) from typical quiescent lesions 3
• The combination of CT and MRI is mandatory when multiple lesions are present, as this pattern raises concern for metastatic disease or multiple myeloma rather than multiple hemangiomas 2

Laboratory Workup

Rule Out Multiple Myeloma

• Complete blood count, comprehensive metabolic panel, serum protein electrophoresis (SPEP), serum free light chains, and quantitative immunoglobulins 2
• Multiple lytic lesions in an elderly patient with myelodysplastic syndrome creates high suspicion for plasma cell dyscrasia, which characteristically presents with lytic lesions that preferentially replace trabecular bone 2
• Elevated alkaline phosphatase would suggest metastatic disease over myeloma 1

Rule Out Metastatic Disease

• Given the patient's age and multiple lesions, metastatic disease from occult primary malignancy (lung, breast, kidney, thyroid) must be excluded 2
• Obtain alkaline phosphatase, calcium, and consider age-appropriate cancer screening if not up to date 1

Advanced Imaging Considerations

FDG-PET/CT (If Initial Workup Indeterminate)

• PET/CT is superior to bone scintigraphy for detecting lytic metastases (sensitivity 89.7%, specificity 96.8%) and can identify additional lesions not visible on CT or MRI in 33-55% of patients with presumed solitary lesions 1, 2
• PET/CT shows metabolic activity in neoplastic lesions but also in aggressive hemangiomas, helping distinguish active from quiescent disease 1
• Avoid bone scintigraphy—it has poor sensitivity (62-100%) and low specificity (48%) for purely osteolytic lesions and will likely miss these lesions entirely 1, 2

Critical Decision Points

If CT Shows Typical Hemangioma Features:

• Coarsened vertical trabeculae ("corduroy" pattern on sagittal, "polka-dot" on axial), no cortical destruction, no soft tissue mass 3
• Proceed with MRI to confirm typical T1 and T2 hyperintensity (due to fat content) and rule out epidural extension 3
• If MRI confirms typical appearance with no aggressive features, clinical and radiographic surveillance every 6-12 months is appropriate 3

If CT Shows Atypical Features:

• Cortical destruction, soft tissue mass, absence of typical trabecular pattern, or mixed lytic-sclerotic appearance 2, 3
• Complete laboratory workup for myeloma and metastatic disease immediately 2
• Consider CT-guided biopsy if imaging and labs remain indeterminate, though biopsy of hemangiomas carries significant bleeding risk and should be avoided if imaging is diagnostic 4, 3, 5

If MRI Shows Epidural Extension or Cord Compression:

• Urgent neurosurgical consultation even in the absence of neurological symptoms, as these "aggressive" hemangiomas can cause rapid neurological deterioration 6, 3, 5
• Preoperative angiography and embolization should be considered if surgical excision is planned, as these lesions bleed profusely 3, 5

Common Pitfalls to Avoid

• Never assume multiple spinal lesions are benign hemangiomas without tissue diagnosis or definitive imaging characteristics—metastatic disease and multiple myeloma are far more common causes of multiple lytic spinal lesions in elderly patients 2
• Do not rely on plain radiographs, which require 50-70% bone destruction before detecting osteolytic changes and will miss early lesions 2
• Do not skip contrast-enhanced MRI—even asymptomatic patients can have epidural extension requiring intervention, and MRI without contrast misses critical soft tissue involvement 1, 2
• Avoid biopsy as first-line diagnostic tool for suspected hemangiomas—imaging characteristics are usually diagnostic, and biopsy carries significant hemorrhage risk 4, 3, 5
• Do not order bone scan—it has unacceptably low sensitivity for lytic lesions and will generate false-negative results 1, 2

Surveillance Strategy

• If imaging confirms typical benign hemangiomas with no aggressive features: repeat MRI at 6 months, then annually for 3 years to ensure stability 3
• Any interval growth, new neurological symptoms, or development of pain mandates immediate repeat imaging and neurosurgical evaluation 6, 3, 5
• The patient's myelodysplastic syndrome increases her baseline risk for developing secondary malignancies, making vigilant surveillance particularly important 2