A 68-year-old white man presented with worsening lower-back pain. An abnormality on the thoracolumbar spine radiographic study (Figure 1) prompted further imaging evaluation, which included a skull radiograph (Figure 2). Upon further questioning, the patient reported occasional throbbing left-sided headaches, which he said were relieved temporarily with over-the-counter analgesics. He denied any recent head trauma or known malignancy and had been in relatively good health recently. Physical examination of the head, neck, and back was unremarkable. ALP, 511 U/liter (35-135 U/liter),
