X-ray may be helpful in the diagnosis of multiple myeloma. Findings on X-ray suggestive of multiple myeloma include punched out bony lesions, generalized osteopenia, and hair-on-end appearance. In some cases, MRI may be needed if X-ray is insufficient for diagnosis.

• Simple radiography is the current gold standard for the initial diagnosis and evaluation of lytic lesions of multiple myeloma.^[1][2]
• The long bones and the spine must always be evaluated while the evaluation of other bones merit consideration based on the patient’s symptoms.
• A series of plain films, or skeletal survey, is essential in not only the diagnosis of multiple myeloma, but also in assessing response, and pre-empting potential complications (e.g. pathological fractures).

• A typical skeletal survey consists of the following films:

• Lateral skull
• Frontal chest film
• Cervico-thoraco-lumbar spine
• Shoulder
• Pelvis
• Femur
• Humerus
• The vast majority of lesions seen on plain radiography are purely lytic. Lytic lesions are sharply defined and “punched-out” in appearance, with endosteal scalloping when abutting cortex. The lesions are sclerotic in only 3% of patients.

• The X-ray is the most inexpensive diagnostic modality for lytic lesions. In some cases, MRI may be warranted, as MRI has a higher sensitivity than X-ray.
• X-rays should be avoided in pregnant patients with multiple myeloma. MRI can be done instead.

• Shown below are images depicting the involvement of skull and spinal cord respectively in a case of multiple myeloma.