1. radiographs of the affected area are recommended for initial evaluation

2. If there is no apparent lesion on radiograph, but the clinical suspicion is high then (CT) or (MRI)

3. initiation of analgesic therapy is indicated before the etiology is determined while further testing is planned

* cancer patients presenting with significant back pain, spinal MRI is indicated, even in the absence of neuro signs

* patients with NO hx of cancer or a distant history are more complex

^ need for biopsy depends on...

whether surgery will be performed,

whether clinical diagnosis using imaging evaluation is sufficient

whether pathological diagnosis is required to confirm metastasis

For patients with no history of cancer, biopsy of skeletal abnormality may be necessary for pathologic diagnosis.

For patients whose cancer is in remission, documentation of a pathologic diagnosis may be necessary especially if this is the first evidence of recurrence or disease progression.

For patients with known history of stage IV malignancy or who are found to have other visceral metastasis on staging or restaging evaluation, clinical diagnosis with one or more imaging modalities may be sufficient to make a presumptive diagnosis of bone metastasis.