Management of Back Pain in Myeloma Patients Using Vertebral Augmentation: A Practical Approach to Elimination of Pain and Improvement of Functional Status

Management of pain and height restoration in multiple myeloma (MM) patients with vertebral compression fractures remains an important area of symptom management among a group of patients that is living longer through advances in therapeutic approaches. Prior studies demonstrated that pain reduction after vertebral augmentation was associated with reduction in patient-reported symptom relief, but clearly more emphasis is needed in this quarter (Julka A, 2012; Mendoza TR, 2012).We report the multidisciplinary approach adapted at our center to management of back pain in MM patients through early and aggressive intervention.

Our study evaluated ten consecutive MM patients from a single center with vertebral compression fractures refractory to conservative treatment and treated with vertebral augmentation. Per our protocol, after a thorough review of pre-procedure magnetic resonance imaging (MRI), fluoroscopic examination of the spine was performed. Symptomatic levels were topographically localized by marking the skin. Demographic, clinical, and procedural data on patients were retrospectively analyzed. The primary measure of outcome is pain relief and functional status, as assessed by the pre and post-procedure Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). Paired-Samples T test is used for comparison of pre and post measures of outcome.

Ten patients with refractory back pain and 36 levels of vertebral compression by MRI were evaluated for potential cement augmentation. Of these levels, 50% (18 levels) were selected for treatment based on fluoroscopic assisted palpation of the spine eliciting a moderate to severe pain-response. A review of the MRI findings of the treated levels showed the absence of traditional MR signal finding of marrow edema; and had little utility in guiding therapy at the time of exam. 15 levels were treated with kyphoplasty alone and 3 levels by a combination of pediculoplasty and kyphoplasty with no adverse outcomes. All patients experienced significant improvement in pain score as measured by VAS. The mean pre and post-procedure VAS were 6.8 and 1.3 (p=0.000), respectively. All patients experienced significant improvement in there functional ability as measured by their ODI questionnaire. Mean pre and post-procedure ODI were 51.4 and 29.8, (p=0.001), respectively.

Solely relying on MRI alone to determine who may benefit from vertebral augmentation and pain relief is not sufficient, and often may preclude patient's potential to gain significant benefit. Careful selection of symptomatic levels may be difficult due to the presence of multilevel MR signal abnormalities, but by utilizing a clinical-based approach and primarily relying on palpation of the spine under direct fluoroscopy, excellent results may be achieved, which is critical to palliative success.

No relevant conflicts of interest to declare.