What Is a Skeletal Survey?

What to Expect When Undergoing This Series of X-Rays

A skeletal survey is a series of X-rays which includes the entire skeleton. Skeletal surveys may be ordered for a variety of reasons in children and in adults. In general, they are used to identify focal or widespread abnormalities of the skeleton.

Skeletal Survey
Verywell / Nusha Ashjaee 

Purpose of Test

A skeletal survey may be performed to investigate known or suspected physical abuse in children, to look for congenital abnormalities of the skeleton, or to look for bone disease in patients with known or suspected cancer. Skeletal surveys are often used in adults with suspected multiple myeloma to look for bone involvement.

Be careful not to confuse a skeletal survey with bone scintigraphy or bone scan. This is a different test which uses a small amount of injected radiotracers to create an image of the skeleton.

Like a skeletal survey, bone scintigraphy can be used to detect the involvement of the bones by cancer, infection, or trauma. However, it is a more complex test which is used in specific situations where simple X-rays of the bones would not suffice.

Whole body CT, MRI, and PET/CT are sensitive tests for the detection of bone involvement by certain types of cancer. These examinations are more costly and time-consuming than an X-ray skeletal survey, but may also find abnormalities that a skeletal survey would miss. Your doctor will choose the best study based on your specific clinical situation and the usual practice at their institution.

Cost and availability of an imaging modality may also factor into the decision. Feel free to ask your physician why one diagnostic test was chosen over another.  

Risks and Contraindications

Any imaging study which uses X-rays involves radiation exposure. A complete skeletal survey may require around 20 X-rays, and is associated with a moderate radiation dose. Overall, there is a low risk of adverse health effects related to radiation exposure from one skeletal survey.

Nevertheless, it is wise to keep radiation doses as low as possible, using only what is necessary to answer the medical question. Certain populations, such as children and pregnant women, are more radiation-sensitive and require special caution.

Before the Test

Your doctor may order a skeletal survey as part of the evaluation for some condition which is suspected to involve the bones. If, for example, a doctor suspects that your child may suffer from a congenital syndrome, he/she may order a skeletal survey to look for bone abnormalities, which may help confirm the diagnosis or determine the extent of disease.

In adults, abnormal blood tests may indicate the presence of certain cancers (such as multiple myeloma) and a skeletal survey may be performed to establish whether there is involvement of the bones. This information will help determine prognosis and guide treatment.

Skeletal surveys may also be ordered in cases of suspected child abuse, particularly in children two years old or less.

Often, this happens in the emergency department when a child presents with a traumatic injury. Some element of the history, physical examination, or radiographic evaluation may lead the doctors to suspect non-accidental trauma. In this case, a skeletal survey may be ordered to look for evidence of other injuries which may increase the suspicion for abuse.

Timing

Allot at least an hour for the test. A typical skeletal survey consists of about 20 individual X-rays (radiographs) of the body. Obtaining the radiographs will take about 25 to 40 minutes. You will also need time to check in and change into a gown.

After the test is done, you will be able to go home. The images will be sent to a radiologist or other physician for interpretation. The results are often available within one or two business days.

Location

Skeletal surveys are often performed on an outpatient basis, in an imaging center which may be associated with a larger hospital. In cases of suspected child abuse, the skeletal survey is often performed in the emergency department as part of the secondary evaluation of trauma.

What to Wear

You will likely be asked to change into a gown. Be sure to wear comfortable clothes that are easy to change into and out of.

Food and Drink

Typically, there are no specific dietary or fasting requirements before a skeletal survey. You may eat and take your routine medications. If in doubt, ask the staff when you schedule the procedure. No oral or intravenous contrast material (dye) is required for the skeletal survey.

During the Test

Pre-Test

On the day of the test, adult outpatients will check in at the imaging center. After this, you will be led to the X-ray suite by a radiology technologist. Be sure to alert the staff if you may be pregnant. You will most likely be asked to change into a hospital gown. Since the skeletal survey requires head-to-toe radiographs, street clothes may interfere with the images.

Skeletal surveys do not require any specific prep work. No oral or intravenous contrast (dye) is used. You will not need an intravenous (IV) catheter.

Throughout the Test

A typical skeletal survey consists of around twenty plain X-rays (radiographs) of your entire body. Specifically, the examination includes radiographs of the skull, chest, abdomen, spine, both arms, and both legs. Depending on the institution, X-rays of the hands and feet will also be obtained.

X-rays can be performed with the patient standing up or lying down. Radiographs of the extremities are usually performed by placing the extremity on a horizontal X-ray table. You will be positioned by a radiology technologist and he/she will be available to answer any questions you may have during the test.

After the Test

After the X-rays are finished, you will be allowed to change and go home. There are no specific precautions to take afterward, and you may resume normal activities immediately.

Interpreting Results 

After the images are obtained, they are usually sent to a radiologist or other physician for interpretation. He or she will communicate the results in the form of a written report. Typically, results take no longer than one or two business days to become available. Contact your primary physician (the one who ordered the test) for results. Often, web-based portals are available which allow you to directly access your radiology report.

If the skeletal survey was performed to evaluate multiple myeloma or other form of cancer, the radiology report will detail whether there are bone abnormalities caused by the disease. Multiple myeloma causes characteristic bone abnormalities which may be called “lytic lesions,” “lucent lesions,” or “punched-out lesions.”

If the skeletal survey was performed for suspected child abuse, the report will state whether there are fractures, of what bones, and how old the fractures appear. Fractures in certain locations are sometimes indicative of non-accidental trauma. Multiple fractures of different ages strongly suggest ongoing abuse.

If a congenital syndrome is suspected, the radiology report will describe whether the appearance of the bones suggests a particular syndrome.

Follow-up

Skeletal survey is used to evaluate for bone disease in patients with multiple myeloma. More advanced tests such as whole-body CT, MRI, or PET/CT may be more sensitive in the detection of disease. Your doctor may opt to perform more advanced imaging if an initial skeletal survey was negative. If you are undergoing treatment for multiple myeloma, a skeletal survey or other imaging study may be performed to see how you are responding to therapy. The follow-up schedule will depend on your specific treatment protocol. Ask your doctor for details. 

If child abuse is still suspected in spite of a normal initial skeletal survey, a repeat examination may be performed after a few weeks. Sometimes, subtle fractures may become more conspicuous over time, and may be detected on the follow-up study.

A Word From Verywell

Information from the skeletal survey forms part of a larger whole. In cases of multiple myeloma, the results of imaging will be factored into the clinical picture when formulating a management plan. As always, it is important to maintain open communication with your health care providers. Do not hesitate to ask why treatment decisions are made, and what factors contributed to any given decision.

You should always feel free to ask for a second opinion about the results of any imaging study. You may request that your radiology images and report be copied for evaluation by physicians at another institution.

           

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Article Sources

  • Prepare for a Diagnostic X-Ray. UCSF Radiology.

  • ACR-SPR Practice Parameter for the Performance and Interpretation of Skeletal Surveys in Children. American College of Radiology. www.acr.org. Revised 2016.

  • Kim JR, Yoon HM, Jung AY, Cho YA, Seo JJ, Lee JS. Comparison of whole-body MRI, bone scan, and radiographic skeletal survey for lesion detection and risk stratification of Langerhans Cell Histiocytosis. Scientific Reports. 2019;9(1). doi:10.1038/s41598-018-36501-1.

  • Rajkumar, S. Vincent, Clinical Features, Laboratory Manifestations, and Diagnosis of multiple myeloma. www.uptodate.com