Paget disease (bone)

Last revised by Rohit Sharma on 23 Apr 2024

Paget disease of the bone is a common, chronic metabolic bone disorder characterized by excessive abnormal bone remodeling. The classically described radiological appearances are expanded bone with a coarsened trabecular pattern. The pelvis, spine, skull, and proximal long bones are most frequently affected. 

Paget disease of the bone is the most common formal name for the condition 24. Synonymous terms such as osteitis deformans, which was the name given by Paget himself to the disease, are of historical interest only. 

Paget disease of the bone is relatively common and can affect up to 4% of individuals over 40 years and up to 11% over the age of 80 years 1. There may be a slight male predilection for Paget disease. Incidence can be considerably higher in the United Kingdom than in other countries 8. It is also common in Australia, New Zealand, Western Europe, and the United States.

Involvement of multiple bones (polyostotic) is more common than single or monostotic disease .

The majority (approximately three-quarters) of patients are asymptomatic at the time of diagnosis, the diagnosis being an incidental finding on imaging 23. Presenting symptoms include:

  • localized pain and tenderness (most common symptom 24)

  • increased focal temperature due to bony hypervascularity (not fever)

  • increased bone size: historically changing hat size was a giveaway

  • bowing deformities

  • kyphosis

  • decreased range of motion

  • signs and symptoms relating to complications (see below)

Polyostotic disease is more prevalent than monostotic type 1. The most frequent sites of involvement are:

  • spine

  • pelvis (often asymmetric)

  • skull

  • proximal long bones

The etiology is not entirely known, but it is a disease of osteoclasts. Viral infection (paramyxovirus) 6 in association with genetic susceptibility has been postulated.

There are three classically described stages, which are part of a continuous spectrum 22:

  • early destructive stage (incipient active, lytic): predominated by osteoclastic activity

  • intermediate stage (active, mixed): osteoblastic as well as osteoclastic activity

  • late stage (inactive, sclerotic/blastic)

These stages correlate well with the imaging findings.

  • elevated serum alkaline phosphatase

  • normal calcium and phosphorus levels

  • increased urine hydroxyproline

There are many Paget disease-related signs, listed here and described in the modality-specific sections below 25:

* pathognomonic signs 25

Plain radiographic and CT features will depend upon the phase of the disease.

The early phase features osteolytic (lucent) regions which are later followed by coarsened trabeculae and bony enlargement. Sclerotic changes occur much later in the disease process.

Additional destructive features may become apparent if malignant transformation occurs. 

  • picture frame sign: Paget disease of the spine frequently manifests with cortical thickening and sclerosis encasing the vertebral margins, which gives rise to this appearance on radiographs in mixed-phase disease

    • this is said to be a pathognomonic appearance 25

  • squaring of vertebrae: on lateral radiographs, flattening of the normal concavity of the anterior margin of the vertebral body also adds to the rectangular appearance

  • vertical trabecular thickening: coarser than the more delicate pattern seen in intraosseous hemangiomas with which it may be confused

These findings are often asymmetric, and for some reason, are more commonly seen on the right side.

  • blade of grass or candle flame sign: begins as a subchondral area of lucency with advancing tip of V-shaped osteolysis, extending towards the diaphysis

    • in rare cases, the disease is isolated to the diaphysis, most commonly in the tibia, rather than subchondral bone, which can cause diagnostic confusion.

  • shepherd crook deformity

  • lateral curvature (bowing) of the femur

  • anterior curvature of the tibia

The overall signal characteristics are variable, likely reflecting the natural course of the disease process in different phases.

Several major patterns of involvement have been described 8,16:

  • dominant signal intensity in Pagetic bone similar to that of fat; most common pattern and probably corresponds to longstanding disease

  • relatively low T1 and high T2 signal alteration (also referred as a “speckled” appearance); second most common pattern: probably corresponds to granulation tissue, hypervascularity, and edema seen in early mixed active disease

  • low signal intensity on both T1 and T2 images; suggesting the presence of compact bone or fibrous tissue; least common pattern: seen in late sclerotic stage

Fatty marrow signal is usually preserved in all sequences unless there is a complication 10.

Tc-99m-MDP is highly sensitive but not specific. It is useful to define the overall extent and distribution of disease.

  • marked increased uptake in all phases of the disease, although in the burnt-out sclerotic quiescent phase uptake may be normal 1

  • Mickey Mouse sign: uptake in the vertebral body and posterior elements forming an inverted triangular pattern on posterior planar imaging resembling the Mickey Mouse silhouette 17,18; also known as the "heart" or "clover" sign 19 and "T" or "champagne glass" sign 20

  • Lincoln sign: diffuse mandibular uptake forming a bearded appearance 21

Symptomatic patients are treated with bisphosphonates (e.g. alendronate) aiming to reduce the bone turnover, promote healing of osteolytic lesions and improve bone pain. Analgesics and non-hormonal anti-inflammatory drugs are also prescribed for pain management. 

Sir James Paget (1814-1899) 27 first described it in 1877 in a case report of a patient he had observed over some twenty years 5.

The condition was initially named by Paget "osteitis deformans", implying an inflammatory etiology. The term "osteodystrophica deformans" is now preferred.

For skull lesions consider ref:

For spinal lesions consider 26:

Consider other fat-containing lesions 26:

Rare, familial forms of Paget disease of the bone have also been described 27:

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