Vertebral multiple myeloma with pathological fracture: the most common etiology for emergency spine surgery in patients with no cancer diagnosis on admission

Abstract

OBJECTIVE Vertebral compression fractures are common in multiple myeloma (MM). Modern treatment paradigms place emphasis on treatment with radiation, with surgery reserved for cases involving frank instability or severe neural compression. However, experience at the authors’ institution has led them to suspect a more prominent role for surgical intervention in some settings. The authors undertook the present study to better understand the incidence of MM in undiagnosed patients who require urgent surgery for pathological vertebral fracture. METHODS The authors reviewed a prospectively collected database of all patients who underwent surgery with the senior author at their main hospital between June 1, 1998, and June 30, 2020. Patients admitted from the emergency room or after transfer from another hospital who then underwent surgery for pathological fracture during the same admission were included in the final analysis. Patients scheduled for elective surgery and those with previous cancer diagnoses were excluded. RESULTS Forty-three patients were identified as having undergone urgent surgical decompression and/or stabilization for pathological fracture. Histopathology confirmed diagnosis of MM in 22 (51%) patients, lung metastasis in 5 (12%) patients, and breast metastasis in 4 (9%) patients. Twelve (28%) patients were diagnosed with other types of metastatic carcinoma or undifferentiated disease. Sixteen of 29 (55%) men and 6 of 14 (42%) women were diagnosed with MM (p = 0.02). Seventeen of 34 (50%) patients who underwent surgery for neurological deficit, 5 of 6 (83%) patients who underwent surgery for spinal instability, and 0 (0%) patients who underwent surgery for pain with impending spinal cord injury were diagnosed with MM (p = 0.12). CONCLUSIONS A majority of patients presenting to the authors’ hospital with no history of malignancy who required urgent surgery for pathological compression fracture were found to have MM or plasmacytoma. This disease process may affect a significant portion of patients requiring decompressive or stabilizing surgery for compression fracture in academic medical centers.

Adherence to the evidence-based recommendations in managing bone health, pain, and mobility of patients with multiple myeloma: a mixed method in the Palestinian healthcare system

“…Additionally, increased bone resorption results from the interaction between bone marrow stromal cells and myeloma tumor cells within the bone marrow microenvironment [ 7 ]. Therefore, the overproduction of osteoclasts and reduced stimulation of osteoblasts leads to imbalanced bone turnover and increased risk of pathologic fractures [ 8 – 10 ]. Stimulation of osteoclast-activating growth factors, cytokine release, and lack of osteoblastic response can lead to the development of destructive bone lesions and diffuse osteopenia [ 4 , 5 , 7 , 11 ].…”

Neurologic Outcomes After Radiation Therapy for Severe Spinal Cord Compression in Multiple Myeloma

“…Bone destruction, caused by diffuse monoclonal proliferations of plasma cells in the bone marrow, is the most frequent disease-defining clinical feature of MM 3,4 . Approximately 80% of patients with MM have lytic bone lesions 4,5 . These lesions lead to an increased risk of skeletal-related events including pathological fractures, back pain, and neurologic compromise through epidural spinal cord compression or cauda equina compression (ESCC/CEC) 4,6,7 .…”