Computed Tomography-Guided SCREW Fixation PLUS Cementoplasty in Myeloma Patients

INTRODUCTION:The aim of this report is to evaluate feasibility, safety and activity of a new procedure of computed tomography (CT) - guided percutaneous screw fixation (PSF) plus cementoplasty for treatment of mielomatous osteolytic lesions with refractory pain and fracture or to prevent impending pathological fractures. The association of scew fixation with cementoplasty allows, compared to cementoplasty alone, a better augmentation of the bone and reduces the risk of cement leakage through a selective injection of the of polymethylmethacrylate (especially in case of lytic lesion of vertebral pedicle).

METHODS: From September 2014 to May 2016 thirteen (13) consecutive patients (eight men and five women, median age 67 years, range 48-78 years) with Multiple Myeloma who had developed painful and symptomatic bone lytic lesions in the pelvis and vertebrae were submitted to the procedure (three patients underwent multiple interventions). This consisted of PSF followed by percutaneous bone-cement injection with an solution of polymethylmethacrylate (PMMA) in eighteen sessions. The procedures were performed into the thoracic vertebrae (three interventions), lumbar vertebrae (nine interventions), pelvis (five interventions, bilateral in one instance) and into a paravertebral mass which involved the fifth and sixth thoracic vertebrae. For the osteosynthesis we used cannulated screws with lateral holes, that allow to selectively inject the cement through the screw avoiding undesired leakage. After the screw insertion, to obtain a better augmentation of the bone, from 8 to 22 ml of PMMA in all the lesions. In two cases, before the PSF and PMMA injection, in order to reduce the volume of the tumor a radiofrequency ablation was performed. All the procedures were performed using local anesthesia, conscious sedation in all patients and antibiotic prophylaxis with ceftriaxone 2 gr i.v. Pain was measured by visual analogue scale (range 0-10), mobility by functional mobility score system with a range from 1 (normal mobility) to 4 (bedridden). Statistical analysis was performed using the test of Wilcoxon.

RESULTS:Technical success was achivied in all patients. The CT scan acquired immediately after the procedure didn't demonstrate any complications such as leakage of cement or incorrect positioning of the screws or undesired burning during thermal ablation. No additional bone fractures occurred during a median follow-up of 19 months (range 3-23 months). Pain relief occurred in all the patients within one month. Median VAS score was 7 (range 4-9), 3 (range1-4) and 1 (range 1-2) before, at one and six months after procedure respectively (p<0.05). Median functional mobility score was 3 (range 2-4), 2 (range 2-3) and 1 (range 1-2) before, at one and six months after the procedure respectively (p<0.05). All patients required analgesic therapy with opiods and no-steroidal anti-inflammatory agents/analgesics (NSAIAs).

Only three patients needed opioid therapy after the procedure.

CONCLUSION:The PSF plus cemetoplasty of the pelvis and vertebrae is safe and effective in patients affected by myelomatous localizzations. The procedure is minimally invasive and allows to stabilize the fracture and prevent pathological fractures with significant pain relief and good recovery of walking ability. Further controlled studies with large series of patients are warranted to confirm these preliminary results.