Population Covered By The Guidance
This pathway provides guidance for imaging adult patients with suspected skeletal metastases from a known or suspected solid organ malignancy
Lead Researcher: Dr Daniel Jarvis
Experts & Contributors: Dr Josefina Medina
Date reviewed: July 2026
Date Published: August 2026
- Plain radiography remains the first-line investigation for bone pain
- Bone scintigraphy is less sensitive and specific than PET/CT and MRI
- In myeloma, bone scintigraphy is unreliable as lytic lesions tend to be photopenic
- MRI is superior for vertebral and marrow disease and for epidural / cord assessment
- MRI is broadly comparable to PET/CT overall, without the ionising radiation
- Suspected cord compression is an oncological emergency
- PET/CT is superior to bone scintigraphy for sensitivity and specificity; it detects extra-osseous disease and unknown primaries
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8. Liu T, Xu JY, Xu W, Bai YR, Yan WL, Yang HL. Fluorine-18 deoxyglucose positron emission tomography, magnetic resonance imaging and bone scintigraphy for the diagnosis of bone metastases in patients with lung cancer: which one is the best?--a meta-analysis. Clin Oncol (R Coll Radiol). 2011;23(5):350-8.
9. Yang HL, Liu T, Wang XM, Xu Y, Deng SM. Diagnosis of bone metastases: a meta-analysis comparing ¹⁸FDG PET, CT, MRI and bone scintigraphy. Eur Radiol. 2011;21(12):2604-17.
10. Harlianto NI, van der Star S, Suelmann BBM, de Jong PA, Verlaan JJ, Foppen W. Diagnostic accuracy of imaging modalities for detection of spinal metastases: a systematic review and meta-analysis. Clin Transl Oncol. 2025;27(5):2316-26.
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Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
 |
None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
 |
Medium | 5-10 mSv |
 |
High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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