Presentation
Renal cell carcinoma and myeloma. Known myeloma. Increasing pain in right shoulder and cervical spine.
Patient Data
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Multilevel degenerative change in the cervical spine.
Absence of part of the right 1st rib from the costovertebral junction in keeping with destruction from an aggressive bone lesion.
Case Discussion
The pathology is only evident on the AP view and is a site where we rarely identify pathology.
In addition, the absence of something is often harder to spot than the presence of something on plain radiographs.
Subsequent CT imaging confirmed a destroyed first rib - in this case from a renal cell carcinoma metastasis or a myelomatous deposit.
It makes a reasonable starter film in a fellowship viva for the powers of observation, providing a differential and how one might manage it clinically.