Case: A 77-year-old man was admitted with a pathological fracture of the right femur, which required intramedullary nailing. He had previously been diagnosed with Pagets disease affecting the right femur and also hyperparathyroidism with a large parathyroid adenoma on Sestamibi scan which had been managed at another hospital. On this admission, his corrected calcium was 2.79 (2.152.55) mmol/l, PTH 643 (1565) pg/ml and alkaline phosphatase 258 (30130) U/l. During his hospital stay, he developed right arm and bilateral leg weakness. MRI scan of the spine revealed a tumour causing destruction of C2 vertebral body and anterior subluxation resulting in spinal cord compression. He was transferred to the neurosurgical unit at Royal Preston Hospital where he had posterior cervical decompression and biopsy. Initial histology suggested osteitis fibrosa cystica due to hyperparathyroidism, although Pagets disease and fibrous dysplasia were considered as differential diagnoses, and the endocrinology team were therefore asked to review him. Review of a previous bone scan demonstrated increased uptake in C2 vertebral body consistent with active Pagets and a review of the pre-operative CT and MRI imaging also confirmed Pagets as the likely diagnosis. He was therefore treated with intravenous zoledronic acid and physiotherapy and his condition improved significantly. Subsequent histology review by a specialist bone histopathologist confirmed the diagnosis of Pagets.
Discussion: Cervical cord compression is a relatively rare complication of Pagets disease. In this case the correct diagnosis was delayed by the initial imaging, which suggested a bone tumour and then the histology which suggested osteitis fibrosa cystica associated with co-existing hyperparathyroidism. Careful review of the previous imaging confirmed previous Pagetic involvement of the cervical spine and features on plain imaging consistent with Pagets which allowed the correct diagnosis to be made, and appropriate treatment to be instituted.