Plain radiography of the skull after investigation for raised calcium

Looking at the skull radiograph showed the characteristic features of Paget's disease of the bone. Author thinks that bisphosphonates might be a line of treatment for this patient ! Examining the skull base of this patient showed massive, diffuse ossification ! It means that the cranial foraminae and the foramen magnum are at high risk of obliteration. Giving anti-resorptive agents might lead to the development of progressive obliteration ( potential for new bone re-deposition). The most common complications of progressive cranial base hyperostosis are hearing loss , headache, exophthalmos , and also vision changes, and symptomatic brainstem compression. And the possibility of foramen magnum syndrome. Strikingly, in some cases the hypersotosis extends to involve C1-2, in this case it leads to diffuse bony ankylosis (atlanto-axial). Ankylosed segments are prone to develop osteoporosis of these segments, causing effectively fracture of C1-2 and sudden death. Decompression surgery is not an easy option, since dealing with a thick sclerotic bone which has been already lost its anatomical landmarks is a real risk and challenge. Therefore, prescribing anti-resorptive agents without proper assessment of the skull base , C1-2 is highly hazardous.