Synopsis
Recognise metastatic bone pain before fracture, cord compression or hypercalcaemia, choose imaging and biopsy by the clinical question and combine systemic cancer control, radiotherapy, stabilisation, antiresorptive treatment, analgesia, rehabilitation and dental safety.
- Bone metastases most often involve spine, pelvis, ribs and proximal long bones and arise commonly from breast, prostate, lung, renal and thyroid cancers.
- Deep progressive night pain is typical; movement- or weight-bearing pain suggests mechanical instability and may precede a pathological fracture.
- First-line assessment of a focal symptomatic peripheral site is plain radiography in two planes, but a normal film does not exclude early marrow metastasis.
- CT best defines cortical destruction and supports operative or radiotherapy planning; MRI is preferred for marrow, soft tissue, neural anatomy and occult fracture.
- Whole-spine MRI is the diagnostic reference standard for suspected metastatic spinal cord compression and must be arranged within 24 hours through the emergency pathway.
- Bone scintigraphy surveys osteoblastic activity but can miss purely lytic or marrow disease; FDG PET-CT, PSMA PET-CT and whole-body MRI are selected by primary biology and purpose.
- Biopsy a solitary, atypical or management-changing lesion when the primary is unknown or imaging is discordant; plan the tract as if primary bone sarcoma remains possible.
- First-line treatment for uncomplicated painful bone metastasis is often palliative external-beam radiotherapy, with a single 8 Gy fraction providing effective pain relief for many adults.
- Radiotherapy does not stabilise an imminently failing long bone immediately. A high-risk lesion needs orthopaedic oncology assessment for prophylactic fixation before or integrated with radiation.
- For neurological metastatic cord compression, give dexamethasone 16 mg as soon as possible, protect movement if unstable and decide urgently between decompressive stabilisation and radiotherapy.
- Treat the underlying cancer with tumour-specific endocrine, cytotoxic, targeted, immune or radiopharmaceutical therapy; local skeletal care remains necessary while systemic response develops.
- Zoledronic acid or denosumab reduces skeletal-related events in defined cancer populations but does not replace analgesia, stabilisation, radiotherapy or anticancer treatment.
- Before repeated antiresorptive treatment, correct calcium and vitamin-D deficiency when appropriate, assess renal function for bisphosphonate and complete preventive dental review.
- Integrate multimodal analgesia, physiotherapy, falls prevention, walking aids, thrombosis prevention and rehabilitation so pain relief translates into useful function.
Key red flags
Progressive unremitting or night bone pain, particularly in spine, pelvis or proximal long bone, requires assessment for metastatic disease and structural failure.
Back pain with weakness, gait change, a sensory level, radicular pain or bladder or bowel dysfunction is metastatic spinal cord compression until urgently excluded.
Functional pain on standing, walking or using an arm through a lytic long-bone lesion suggests impending fracture and needs same-day load protection and orthopaedic review.
Sudden severe pain, deformity or inability to weight bear after minor force indicates a completed pathological fracture requiring stabilisation planning before radiotherapy alone.
Thirst, polyuria, constipation, vomiting, confusion or arrhythmia may reflect malignant hypercalcaemia and requires calcium, renal, electrolyte and ECG assessment.
A solitary destructive lesion or an atypical pattern without secure cancer histology could be primary bone sarcoma, myeloma or infection and must not undergo unplanned fixation or radiotherapy.
Jaw pain, exposed bone, a non-healing extraction site or new thigh or groin pain during antiresorptive treatment raises osteonecrosis or atypical femoral fracture.
Investigation priorities
Assess a symptomatic long bone or focal peripheral site for lysis, sclerosis, cortical loss, periosteal change and completed fracture.
Detect marrow replacement, soft-tissue extension, occult fracture and epidural, cord, cauda-equina or nerve-root compromise.
Management branches
A patient with known or possible cancer develops persistent localised skeletal pain.
- Examine tenderness, load-related pain, gait, limb function and full spinal neurology and ask explicitly about night pain, weakness and bladder or bowel change.
- Obtain site-appropriate radiographs and CT or MRI, protect weight bearing when failure is possible and stage the skeleton according to primary tumour biology.
- Biopsy a solitary or discordant lesion through a planned route, then combine systemic cancer treatment with radiotherapy, stabilisation, antiresorptive and rehabilitation decisions.