Suspected myeloma — skeletal assessment

IMWG imaging consensus 2019

The radiographic skeletal survey has been superseded. Modern criteria define myeloma-defining bone disease by lytic destruction on cross-sectional imaging or by focal marrow lesions on whole-body MRI, and both detect disease in patients whose radiographs are normal. Vetting a skeletal survey request usually means replacing it.

Monoclonal paraprotein, unexplained anaemia, hypercalcaemia, renal impairment or bone pain, with a plasma cell disorder suspected or established and skeletal disease burden required.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Red flags

These accumulate rather than exclude. Back pain with one of these is a different question from back pain.

Cord features

Weakness, a sensory level, hyperreflexia, sphincter or gait disturbance. This changes how much of the spine is imaged, not which scanner is used — a sensory level says the cord is involved but not reliably where, and the lesion is often several segments higher.

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

Whole-Body MRI — myeloma (MY-RADS style)

Whole-Body MRI

What we'd amend, and why

Myeloma replaces marrow before it destroys cortex, which is why an imaging test that looks at bone rather than marrow is a late detector. T1 Dixon shows fat-signal replacement directly and diffusion-weighted imaging shows the cellularity, so focal lesions are visible while the radiograph and even CT are normal. The protocol is unenhanced, which suits a population with frequent renal impairment, and the same station geometry and b values acquired at baseline are what make later ADC-based response comparison possible.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwaystandard — Adults — plasma cell disorder
rulerule-mr-device-screening — MR safety screening for implants and foreign bodies; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(1)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

MR safety screening for implants and foreign bodies
Complete the MR safety questionnaire, verify implant labelling and its stated conditions of use against this scanner and this protocol, and ensure no ferromagnetic object enters Zone IV.
Radiographer at the scannerBefore the scan
Flags back if: An implant or retained foreign body that is MR Unsafe, unlabelled, or cannot be identified; or an MR Conditional device whose stated conditions this scanner or the requested protocol cannot satisfy; or a credible unexcluded intraocular metallic foreign body history.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Neurological signs — suspected cord compression, not a burden question

Role	Study & protocol	Why this answers the question
First line	MRI Whole Spine MRI Whole Spine — suspected metastatic cord compression usually appropriate	Myeloma is the disease in which this presentation is commonest and most often mishandled, because the request that arrives is a survey request. Vertebral involvement is the rule rather than the exception, collapse can be atraumatic, and epidural soft-tissue extension compresses the cord without any fracture at all — so weakness, a sensory level, gait disturbance or sphincter disturbance converts a staging question into an emergency. The standard is whole-spine MRI within 24 hours of the suspicion and sooner if the deficit is progressing, because ambulatory status before treatment is the best predictor of ambulatory status after it. Coverage is whole-spine for the reason that defines this disease: skip lesions are the norm, and the compressive level is frequently not the painful one. The protocol is unenhanced — sagittal T1 and a fluid-sensitive sequence to find the marrow disease, sagittal T2 for the degree of cord deformity, axial sections through each significant level — which matters here because renal impairment is common at myeloma presentation and is not a reason to delay this scan. Dexamethasone and the referral to haematology, clinical oncology or spinal surgery are started while the scan is being arranged.
Second line	Whole-Body MRI Whole-Body MRI — myeloma (MY-RADS style)	Disease burden still has to be established, and the whole-body study is how — but it follows the cord question rather than replacing it. Where local capacity allows, the whole-spine sequences can be acquired as the opening stations of the same sitting and reported immediately, which answers both questions without two attendances; what must not happen is the emergency waiting for a whole-body slot.

Entered from cord features or a progressive neurological deficit on the request. Leave those facts unset and the card behaves exactly as it did before.
A patient who cannot have MRI is not a patient who gets a radiographic survey instead. CT of the relevant segments with reformats, or CT myelography, is the substitute and the urgency is unchanged.

Adults — plasma cell disorder

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	Whole-Body MRI Whole-Body MRI — myeloma (MY-RADS style) usually appropriate	Myeloma replaces marrow before it destroys cortex, which is why an imaging test that looks at bone rather than marrow is a late detector. T1 Dixon shows fat-signal replacement directly and diffusion-weighted imaging shows the cellularity, so focal lesions are visible while the radiograph and even CT are normal. The protocol is unenhanced, which suits a population with frequent renal impairment, and the same station geometry and b values acquired at baseline are what make later ADC-based response comparison possible.
Problem solving	MRI Whole Spine MRI Whole Spine — suspected metastatic cord compression	When the presentation includes back pain with any neurological symptom or sign, the question stops being disease burden and becomes cord compression, which is an emergency with a different urgency and a different protocol. Whole-spine sagittal coverage exists because skip lesions are the norm in myeloma.
Second line	Spinal radiograph Spinal radiograph — AP and lateral	Targeted radiographs of a painful site still answer a specific mechanical question — cortical destruction, fracture, and the risk of one — quickly and cheaply. What they cannot do is exclude disease: a lytic lesion is not visible on a radiograph until a large proportion of trabecular bone is lost, which is why the whole-body radiographic survey is no longer a staging test.

Pitfalls

Accepting a radiographic skeletal survey request at face value. It is the study most likely to return normal in a patient with myeloma-defining bone disease.
Reading a negative bone scintigram as reassurance. Purely lytic myeloma is often photopenic, and bone scanning is the wrong survey for this disease.
Missing the neurological history in the request. Back pain plus any weakness, sensory change, gait disturbance or sphincter disturbance converts this into an urgent cord compression pathway, not a staging one — whole-spine MRI within 24 hours, with steroids and the specialist referral started in parallel rather than after the report.
Applying diffuse marrow diffusion signal in a young or anaemic patient as disease. Red marrow reconversion mimics infiltration and is a technique-driven confounder.
Truncating whole-body coverage above the knees when symptoms or known disease are more distal.

Priors — what to pull first

Where a previous whole-body MRI exists, the b values and station positions used on it dictate the protocol for this one — protocol drift is what destroys serial comparison in whole-body imaging.
Recent granulocyte colony-stimulating factor or chemotherapy should be recorded: both change marrow signal globally and are routinely misread as diffuse infiltration or as progression.

What makes a good request

The IMWG consensus replaced conventional radiographic skeletal survey with whole-body low-dose CT as the recommended first imaging in monoclonal plasma cell disorders, with whole-body MRI the most sensitive technique and the one that detects focal marrow lesions before cortical destruction occurs.
Whole-body low-dose CT has no study node in this vocabulary, so where local practice uses it the request must be routed outside this pathway. The MRI pathway below is the alternative the same consensus endorses.
The distinction matters clinically: two or more focal lesions on whole-body MRI is myeloma-defining in an otherwise smouldering patient, which converts observation into treatment.
The whole-body MRI protocol is unenhanced, so renal impairment — common at presentation and a reason contrast studies get deferred — is not an obstacle to it.
Back pain with any neurological symptom or sign is not a burden question. Myeloma causes cord compression from vertebral collapse and from epidural soft-tissue extension, and the standard is whole-spine MRI within 24 hours of the suspicion, with dexamethasone and the acute oncology or spinal surgical referral started alongside the booking rather than after the report. This card forks on that fact.

Scoring this once it is done

The classification and risk tools this question ends in.

SINS (Spinal Instability Neoplastic Score)Bone-RADS (Bone Lesion Scoring)RECIST 1.1 Tumor Response

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

MRI Whole Spine — suspected metastatic cord compression Whole-Body MRI — myeloma (MY-RADS style)Spinal radiograph — AP and lateral

Confirm locally

Whole-Body MRI — myeloma (MY-RADS style): timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.