Today´s images belong to a 76-year-old man with pain in the back. Antecedents of urothelial carcinoma.
PA chest radiograph was normal and radiographs of the dorsal spine were taken.
What do you see?
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Findings: AP view of dorsal spine shows fixation screws in the lower spine and partial vertebroplasty of D12. The most important finding is that the left pedicle of D8 is absent (A, circle). In the lateral view, the posterior wall of the same vertebra is not seen (B, circle).
The findings are more evident in the cone down views (C-D, circles). In this particular case I was lucky because the superimposed air of the left main bronchus allows an unimpeded view of the missing pedicle.
Review of a recent chest CT demonstrated a lytic lesion in the body and pedicle of D8 (E-G, circles) that were no reported.
Final diagnosis: metastasis to D8 discovered in the plain film of the spine and overlooked in a previous CT.
Congratulations to BujarB, who was the only one to discover the missing pedicle (my hero!)
You may think that this case is difficult (only one of seven found the lesion). In the old times our routine included looking at the pedicles in the AP view of dorsal and lumbar spine. To familiarize you with the appearance of the normal spine, an AP view is shown below.
Teaching point: remember to look at the pedicles in the AP view. A missing pedicle in a patient with a known primary tumor is highly suspicious of metastasis.