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Kyriakou et al. Blood Cancer Journal (2019) 9:27
https://doi.org/10.1038/s41408-019-0187-7 Blood Cancer Journal
ARTICLE Open Access
Theroleofcementaugmentationwith
percutaneous vertebroplasty and balloon
kyphoplasty for the treatment of vertebral
compression fractures in multiple
myeloma: a consensus statement from the
International Myeloma Working Group
(IMWG)
Charalampia Kyriakou
1,2
, Sean Molloy
2
, Frank Vrionis
3
, Ronald Alberico
4
, Leonard Bastian
5
, Jeffrey A. Zonder
6
,
Sergio Giralt
7
,NoopurRaje
8
,RobertA.Kyle
9
,DavidG.D.Roodman
10
, Meletios A. Dimopoulos
11
,
S. Vincent Rajkumar
12
, Brian B. G. Durie
13
and Evangelos Terpos
11
Abstract
Multiple myeloma (MM) represents approximately 15% of haematological malignancies and most of the patients
present with bone involvement. Focal or diffuse spinal osteolysis may result in significant morbidity by causing painful
progressive vertebral compression fractures (VCFs) and deformities. Advances in the systemic treatment of myeloma
have achieved high response rates and prolonged the survival significantly. Early diagnosis and management of
skeletal events contribute to improving the prognosis and quality of life of MM patients. The management of patients
with significant pain due to VCFs in the acute phase is not standardised. While some patients are successfully treated
conservatively, and pain relief is achieved within a few weeks, a large percentage has disabling pain and morbidity and
hence they are considered for surgical intervention. Balloon kyphoplasty and percutaneous vertebroplasty are
minimally invasive procedures which have been shown to relieve pain and restore function. Despite increasing
positive evidence for the use of these procedures, the indications, timing, efficacy, safety and their role in the
treatment algorithm of myeloma spinal disease are yet to be elucidated. This paper reports an update of the
consensus statement from the International Myeloma Working Group on the role of cement augmentation in
myeloma patients with VCFs.
Introduction
Multiple myeloma (MM) is a haematologic malignancy
characterised by infiltration of the bone marrow by
plasma cells which can be associated with lytic bone
disease causing severe bone pain, pathological fractures
and neurological compromise including cauda equina/
spinal cord compression. Up to 90% of the myeloma
patients develop osteolytic lesions during the course of
their disease
1–3
and 70% of patients are affected at some
stage by osteolytic/osteopenic disease of the spine
4
. Sev-
eral skeletal events over a patient’s lifetime result in
© The Author(s) 2019
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Correspondence: Charalampia Kyriakou (c.kyriakou@nhs.net)(charalampia.
kyriakou1@nhs.net)(rmgvchr@ucl.ac.uk)
1
University College London and Northwick Park Hospitals, London, UK
2
Royal National Orthopedic Hospital, Stanmore, UK
Full list of author information is available at the end of the article.
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substantial morbidity, mortality
5
and increased healthcare
costs.
The introduction of new targeted therapeutic agents
in combination with stem cell transplantation has led to
a remarkable evolution in the management of myeloma
over the last 2 decades
6,7
. Patients with myeloma are
living much longer because of improved treatment of
the primary disease. Haematological medical manage-
ment aims at improving the survival of these patients
and maintaining their quality of life (QoL). It is thus
especially important to treat the osteolytic bone disease
and vertebral compression fractures (VCFs) of the spine
in a timely manner. Historically, haematologists treated
the pain associated with VCFs with radiotherapy and
strong opioids. However, these treatments have their
own side effects and do not stabilise the fracture. In
many cases, pain remains disabling and some patients
develop progressive deformities. Some of the fractures
also fail to heal and may result in significant
chronic pain.
Treatment of the spine is directed towards keeping
the patient pain free, ambulatory and continent. A
secondary aim should be to minimise any progressive
kyphotic deformity which can lead to a poor QoL.
Vertebrae that are severely compressed can lose more
than 50% of their original height
8
. Following a spinal
fracture, there is an exponential risk of a subsequent
one due to an abnormal sagittal balance that ensues and
the additional compressive forces on the anterior aspect
of the spine
9–11
. Moreover, the patients adopt a
kyphotic posture to minimise pain from their VCFs and
to compensate for the weakness of the spinal muscu-
lature
12–14
. Patients with multiple fractures have
reduced activities of daily living, pulmonary and gastric
problems and have increased morbidity and mortal-
ity
11,13
. The kyphotic posture significantly reduces lung
function
15
and pulmonary disease is the commonest
cause of death in women with VCFs
11,16,17
.Another
major consequence of the spinal deformities is the
psychological impact to these patients who often suffer
from depression, anxiety and low self-esteem, with
accompanying loss of QoL
18–20
.
The introduction of minimally invasive procedures such
as balloon kyphoplasty (BKP) and percutaneous verteb-
roplasty (PV) has enabled the vast majority of the treated
patients to return to a near normal level of function
within a very short period of time with excellent pain
relief
21–33
.
In 2008, a consensus statement was published by the
International Myeloma Working Group (IMWG) on the
role of vertebral augmentation with cement in MM
34
.
The aim of this paper is to update the previous
recommendations by the IMWG considering new
published data.
Overview of vertebral cement augmentation procedures
(VCPs), PV and BKP versus alternate options as therapy for
VCFs
The PV and BKP have been extensively used in the
treatment of painful osteoporotic and cancer-related
VCFs. The value of these modalities in treating osteo-
porotic VCFs was questioned because of the results from
two prospective randomised trials that showed no benefit
when compared with a sham procedure in relieving
pain
35–40
. Kallmes et al. had a simulated surgical proce-
dure as control group without cement augmentation, and
in the study by Buchbinder et al., the patients had a sham
procedure which entailed injection of a local anaesthetic
into the periosteum over the lamina and pedicle. Some of
the criticisms of these two studies, the patients most in
need of cement augmentation and therefore potentially
the ones with the maximum amount of benefit, were
possibly excluded from the studies on the basis that they
would not allow themselves to be randomised into one of
the two groups. The patients enrolled in the studies may
have had facet joint-related pain and not the severe pain
that one would usually associate with an acute VCF. This
may explain why the patients did not show improvement
following VP. It is recognised clinically that the severe
pain due to an acute VCF subsides if the fracture starts to
heal but patients can experience residual pain related to a
resultant deformity. The deformity alters the facet joint
mechanics and facet-related pain can ensue. Wilson et al.
reported that a third of the patients technically suitable
for VP for an osteoporotic fracture, responded beneficially
to a facet joint injection alone. In this study, the percen-
tage of the enrolled patients may had facet-related pain
rather pain from the original fracture
41,42
. Significant
reduction in mortality and morbidity using cement aug-
mentation with BKP or VP versus nonsurgical manage-
ment was reported in retrospective analyses
25,43
.
However, these studies reported outcomes on osteo-
porotic and not on cancer patients. In the cancer popu-
lation, prospective and retrospective analyses reported
favourable results in the treatment of painful metastatic
cancer and myeloma-related VCF’s with PV and
BKP
24,29,44–49
. The prospective randomised controlled
trial Cancer Patient Fracture Evaluation (CAFE), provided
evidence for the superiority of BKP versus non-surgical
management (NSM) of painful VCFs. 134 cancer patients
were enrolled, of whom 49 had MM. Of these, 22 were
randomly assigned to BKP and 27 to NSM
33
. BKP was
found to be significantly more favourable than NSM
offering rapid and sustained pain relief at 1 year, as well as
improved back function, QoL, activity, reduced use of
analgesics and bed rest days. Similarly, other studies have
reported beneficial results of BKP and PV in rapid pain
control, functional and QoL in MM patients with
VCFs
24,29–31,45,48,50–52
.
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Additional kyphoplasty was more effective than addi-
tional radiation or systemic therapy in terms of pain relief,
reduction of pain associated disability and of fracture
incidence of the entire thoracolumbar spine
44
. It is very
important that we do not deny treatment in MM patients
that may be very effective in relieving the pain from their
acute VCF. They may require VCP (VP or BKP) to give
them rapid relief of their pain and return them to function
as soon as possible. The pain relief from cement aug-
mentation has been sustained over long post-operative
periods in patients with MM
21,30,50,53,54
. Many patients
with myeloma who get over the acute fracture pain may
benefit from facet joint injections for facet-related pain
due to the kyphotic deformity.
The evidence on bracing in the management of osteo-
porotic VCFs is conflicting and the role of the use of
external supportive devices including rigid thoracolumbar
spinal orthosis (TLSO) or hyperextension braces is yet to
be defined
55
. Splinting of fractures and thermoplastic
bracing of spinal deformities has been used for many years
to treat disability and pain. Bracing for 8–12 weeks has
also been used for the treatment of VCF’s related to
myeloma
52
. This may be all that is needed to give the
patients pain relief from their acute fracture pain. The
thermoplastic brace may also give temporary stability to a
fractured spine and to patients with sternal fracture
56
while chemotherapy is initiated. The most important
treatment modality is the systemic anti-myeloma therapy
to get the myeloma under control. After one or two cycles
of systemic anti-myeloma therapy, cement augmentation
(PV and BKP) can be performed if in fact the acute
fracture pain is still present. Often these patients have had
relief of their acute fracture pain with the thermoplastic
brace alone or with the addition of 4–6 weeks of medical/
conservative treatment. This means that the patients may
not need cement augmentation. Instead if they have
chronic pain of a lower intensity over their kyphotic
deformity they may benefit from some facet joint
injections.
A small group of myeloma patients present with a soft
tissue myelomatous mass within the spinal canal that can
result in spinal cord or cauda equine compression. These
patients often present with neurological deficits and each
case needs to be assessed individually. MRI scanning is
clearly imperative but a CT scan with soft tissue windows
will help to delineate whether the neural compression is
due to bone or soft tissue. If the compression is due to a
soft tissue mass with associated neurological impairment,
then this may be amenable to steroids/chemotherapy and
immediate radiotherapy. Patients with cord compression
and no neurological deficit may not need radiotherapy
because chemotherapy and steroids have been shown to
result in excellent resolution of the soft tissue myeloma-
tous mass. Ideally, if patients can be treated with steroids,
radiotherapy and chemotherapy and have a very good
resolution of their symptoms in 24 h, then they may not
need surgical decompression and stabilisation. All deci-
sions regarding patients with spinal cord compression
need to be taken into conjunction with an experienced
spinal surgeon. Clearly, if a patient has spinal cord or
cauda equina compression and has significant neurologi-
cal sequelae then they may require urgent surgical
decompression and associated fixation. The aim however
in patients with haematological malignancies should be to
try and avoid placement of screws/fixation of the spine.
The metalwork has a higher than normal risk of failure
because the bone is very weak due to MM causing sec-
ondary osteoporosis. In addition, there is a higher risk of
metalwork infection because the patients are immuno-
suppressed during their conventional chemotherapy,
immunotherapy and stem cell transplantation. After
resolution of the intraspinal mass with chemotherapy,
radiotherapy and steroids the fractured vertebra may need
to be augmented with cement to treat the acute fracture
pain but also to give mechanical support to the anterior
and middle columns of the spine
57
thereby preventing
further collapse of the vertebral body. Further collapse,
particularly into kyphosis, may lead to spinal cord com-
promise because of the deformity.
Patients that present with no intraspinal soft tissue
mass, but overt bony destruction and dubious spinal
stability are another important group of patients. A pos-
terior vertebral wall defect or pedicle/facet fracture may
lead one to question the spinal stability in this patient
group. Often all that is needed is a spinal brace to keep
them out of pain while the spine confers itself stability by
producing bridging bony osteophytes
58,59
. This appear-
ance is similar to diffuse idiopathic skeletal hyperostosis
60
.
It is a phenomenon that may be accelerated by or the
result of treatment with bisphosphonates. This is a very
interesting finding and warrants further research to see
whether patients with myeloma present a completely
different clinical problem than patients with osteolytic
metastases due to solid tumours.
The following is the consensus statement for recom-
mendations for spinal support and cement augmentation
from the International Myeloma Working Group. MM
patients with significant pain at a fracture site should be
offered a BKP or PV procedure and the procedure should
be performed within 4–8 weeks unless there are medical
contraindications (Tables 1and 2, Fig. 1a, b).
Identification of patients suitable for vertebral
augmentation
●Careful assessment to determine the severity and site
of the pain
61
. Patients with acute fracture pain
should be considered and not the patient with facet
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Table 1 Indications for cement augmentation
(1) Absolute indications for cement augmentation of a vertebral body or bodies due to fracture:
•Persistent significant pain from a fractured vertebral body confirmed on MRI scanning with STIR images. This fracture could be acute, sub-acute or
chronic (often has a fracture cleft) and has not healed
•Persistent significant symptoms which have not resolved with normal conservative measures after 4 weeks of treatment affecting daily activities
•Significant pain due to a fractured vertebral body affecting activity
•Significant pain associated with significant change in disability in conjunction with a new event
•Acute patient-delayed for medical reasons
•Selective chronic fractures
•Complications for myeloma should be treated first and pain is not defined by a specific VAS number
•Timing is important, especially newly diagnosed patients. Immediate referral for treatment for very severe pain requiring high dose of analgesics
(2) Relative indications for cement augmentation of a vertebral body or bodies due to fracture:
•Fracture of the thoracolumbar junction (T10–L2) that could result in a significant kyphotic deformity and therefore morbidity
•Loss of vertebral body height (progressive as evidenced by sequential erect x-rays)
•Posterior wall defect or destruction of a pedicle/pars which may potentially render the affected area of the spine unstable and at risk of fracture/
neurological insult new tumour classification system to delineate vertebral bodies at risk of impending fracture as a result of metastatic spinal
disease
82,83
. May be used for classification for myeloma patients as well but this needs to be myeloma spinal disease validated
(3) Conditional or prophylactic indications for cement augmentation of a vertebral body or bodies due to fracture:
(A) Loss of vertebral height sufficient to affect functional activities
•Fracture at T10–L2 (thoraco-lumbar junction) consider cement augmentation; below L2 is not as significant
•Only if progression over time; follow up with standard x-rays every 1–3 months
(B) Risk of impending fracture
•Need to take into consideration the aggressive nature of the disease and patient activity
•“Impending fractures”hard to determine
•Need for clinical trials
Table 2 Immediate vertebral cement augmentation
Acute VCF with severe pain VAS ≥6
•However, often patients can be temporally stabilised in thermostatic TLSO (thoracolumbar sacro orthosis) to adequately control their pain while
medical management is initiated
•Following 1–2 cycles of chemotherapy if patients present with poor performance status, septic, or have hyperviscosity problems that can be
contraindications to undergo the procedure. Patients can be still treated with cement augmentation if still clinically indicated. The analgesics,
bisphosphonate and chemotherapy treatment can provide pain relief and may alleviate some of the fracture pain.
Subacute VAS 4–6
•Patients with VCFs that are borderline should be treated with chemotherapy, bisphosphonates and conventional pain relief measures and if these
fail then cement augmentation should be considered. If the pain persists or worsens or there is a risk for further vertebral collapse, then early
intervention is required if stabilising the spinal structure and/or restoring the vertebral body height are critical.
•If the pain persists at the site of a previously diagnosed fracture the cement augmentation is still indicated if the pain is thought to be fracture and
not facet joint related pain. These patients often have a fracture cleft in the vertebral body on the MRI imaging.
•VAS 1–3 Watchful surveillance with periodic skeletal survey (or other imaging as appropriate)
VAS visual analogue pain scores, VCF vertebral compression fractures
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joint-related pain. The clinical picture should be
confirmed with MRI scanning. The most useful MRI
images to show an acute or on-going painful fracture
are the sagittal STIR and T1 weighted sequences.
The T1 weighted images may be more helpful in
diagnosing a VCF in a MM patient than the STIR
images. In addition, T1 images may also show the
fracture line.
●MRI is crucial to document any radiological nerve
root/cauda equina or spinal cord compression.
●CT scan with sagittal and coronal reconstructions
may be needed to assess if there is spinal instability.
A SINS classification can be helpful when
determining the stability of the spine. If there is a
posterior wall defect or pedicle/facet joint
involvement, then CT can determine the safety of
cement placement within the vertebral body. If
patients get a recurrence of pain after a successful
cement augmentation, then sagittal T1 and STIR
images of the spine should be repeated to see if there
is a new fracture that could develop following
myeloma treatment.
●Assessment of myeloma disease status and therefore
risk related to anaesthetic and any cement
augmentation procedure. This includes potential
anti-myeloma treatment requirements and risk for
infection and bleeding. Coordination of procedure
with treating haematologist/oncologist to avoid
anaemia, leukopaenia and/or thrombocytopaenia
related to systemic anti-myeloma therapy.
Timing of vertebral cement augmentation (PV or BKP)
The CAFÉ Trial investigated early intervention in can-
cer patients who had VCF’s treated with BKP. The func-
tional outcome (RDQ) was superior for the patients
having BKP in the 1st month compared to the patients
who received non-surgical treatment. The patients in the
BKP group showed a marked reduction in back pain and
Fig. 1 Myeloma Spinal Pathway. a Myeloma spinal pathway for myeloma patients presenting with spinal disease with no neurological symptoms.
bMyeloma spinal pathway for myeloma patients presenting with spinal disease and associated neurological symptoms
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required less pain relief. This is important for myeloma
patients since most of them have a degree of renal
impairment. In addition, improvement of function and
mobility can reduce thrombotic and infection risk.
Therefore, early intervention within 4–8 weeks
62,63
of
VCF’s with cement augmentation not only treats the pain
associated with the fracture but in addition improves
clinical outcome and QoL
52
(Table 2).
Number of levels to be considered for treatment
For patients with multiple VCF’s and significant pain,
the maximum number of levels that should be augmented
at a time should be determined by the operator. There is
no upper limit for total number of vertebrae that should
be treated in one intervention. The panel’s recommen-
dation is that it is appropriate to treat up to 3 levels at a
time and any decision treating more levels than this
should be taken with caution. The reason for this is that
cement embolus to the lungs may occur compromising
respiratory function. Cement augmentation without
cement leakage into the disc above or below should not
increase the risk of adjacent vertebral body fracture.
Cement leakage rates with BKP are reported to be less
than with VP
28,31
. This is also the consensus of the panel.
The highest level of cement augmentation
Cement augmentation of the spine is possible at all
spinal levels. The C2 vertebral body can be augmented via
a trans-oral or submandibular route. The C3–C7 vertebral
bodies can be accessed and augmented through a stan-
dard open anterior cervical approach
64–66
or percuta-
neously if the experience is available. The thoracic and
lumbar vertebral bodies can be augmented with cement in
the standard transpedicular or extrapedicular approach.
Pain due to fractures from T1 to T4 rarely needs to be
treated with cement augmentation because the pain
usually settles with conservative management. Sarcro-
plasty can be performed if there is evidence of sacral
insufficiency fractures.
The method of vertebral cement augmentation
Published studies report contradicting results for
cement augmentation
38–40,48,67–71
. Although there has
been a change in emphasis from VP to BKP, the evidence
for one procedure over the other is debatable. A meta-
analysis of randomised and non-randomised trials of VP,
BKP and NSM in patients with VCF due to osteoporosis
31
has found that BKP was better than VP or NSM in
reducing disability. Both BKP and VP were better for
reducing pain (mostly during the first 8 weeks) and sub-
sequent fracture risk (by about 50%) when compared to
NSM. There was no difference between BKP and VP for
these parameters. Cement leakage into the canal, lungs or
other major organs was less for BKP than for VP. BKP was
better in restoring mid-vertebral height and in changing
kyphotic angle than VP and was also associated with less
incidence of refracture. BKP, which involves inflation of a
balloon tamp to create a void in the vertebral body,
controls the delivery of cement better than PV. Patients
with multiple VCF’s may become very kyphotic in the
thoracic and lumbar regions of the spine. A hyperkyphosis
results in a positive sagittal alignment also termed sagittal
imbalance. Patients with a positive sagittal balance find it
more difficult to stand in the upright posture and in
attempting to do so expend more energy. Poor sagittal
alignment has been shown to be a strong predictor of
disability
72
. There has been debate as to the potential for
BKP and PV to restore vertebral body height following a
VCF. Some papers however report an improvement in the
Cobb angle (degree of kyphosis) following BKP
50,54,73,74
for VCF’s related to MM. Similar outcomes of KIVA
implant to BKP vertebral augmentation were reported in
patients with VCFs secondary to cancer and osteo-
porosis
75–79
. More research is needed to answer this
question definitively. In addition, direct comparison of the
complications of NSM, VP and BKP and the optimal
timing for VCF treatment in MM patients are questions
that could be answered in a prospective randomised,
controlled clinical trial.
Use of radiotherapy
The use of radiotherapy for local disease control and
palliation should be used judiciously and sparingly
depending on the patient’s presentation, need for urgent
response, and prior treatment history and response. MRI
and CT scans are crucial to differentiate between a soft
tissue myelomatous mass in the spinal canal from bony
encroachment. The reason for this is that radiation
therapy is very effective in reducing the size of a soft tissue
myelomatous mass but not effective if there is bony neural
compression and does not stabilise the VCF.
Radiotherapy should be limited as much as possible to
spare the patient’s marrow function. Current systemic
combination therapies of steroids with novel agents work
rapidly and should decrease the need for palliative
radiotherapy. Radiation therapy may be appropriate for:
(1) Patients with a soft tissue mass or plasmacytoma
that has not resolved with systemic therapy
(2) Patients who cannot receive systemic therapy
(3) Relapsed refractory patients
(4) Palliative approach for poor performance status
patients
(5) When mass is associated with severe pain
(6) Location of plasmacytoma precluding use of BKP or
PV; e.g. tumour impacting posterior part of the
vertebral body close to spinal cord and nerves.
Receiving radiotherapy and the dose of previous
radiotherapy are not contraindications for cement
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augmentation (PV or BKP) if it is needed. The need and
timing of a cement augmentation procedure for patients
that have been irradiated depends on the patient’s pain
(Fig. 2). The cement augmentation procedures are per-
formed through small stab incisions and therefore the
usual concerns over wound healing do not exist. Patients
that have a posterior wall defect (associated with a soft
tissue mass encroaching the spinal canal) or pedicle/facet
joint involvement may need supplementary cement aug-
mentation despite having received radiotherapy to stabi-
lise the anterior and middle columns of the spine. Planned
vertebral augmentation 4–8 weeks later (or after the
second cycle of chemotherapy) is appropriate for patients
with relative vertebral instability. The aim of the cement
augmentation is to halt further collapse of the fractured
vertebral body that could result in progressive kyphosis
and secondary neural compromise.
Overall, the proposed algorithm for spinal support in
myeloma presenting with VCFs or spinal cord compres-
sion is summarised in a flow diagram in Fig. 1b. The first
major decision point is the presence or absence of signs
and/or symptoms of neurological deficit. Obviously, if
there is, this is an urgent matter and recommendations
proceed accordingly. Once the situation has been
Fig. 2 A 57-year-old male presented with bilateral leg weakness (3/5 MRC), sensory disturbances and back pain, catheterised with good
anal tone. a Initial MRI revealed T10 collapse with tumour in canal causing spinal cord compression. bSoft tissue CT windowing confirmed that it
was soft tissue tumour without bone element in the spinal canal. The patient was treated with dexamethasone and radiotherapy for cord
compression, had TLSO brace fitted for relative stability and received 2 cycles of chemotherapy for kappa light chain myeloma. cMRI was repeated
for persistent severe back pain (VAS 8/10) and reassessment of cord compression. Clinically power was 5/5 in both legs. The MRI confirmed soft tissue
mass response and spinal stability. Patient had cement augmentation with BKP at T10 to relieve the pain and 24 h later VAS was 1/10
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assessed, stabilised and treated, then cement augmenta-
tion can be an option if there is persistent pain. For
patients without neurologic compromise, imaging and
multi-disciplinary assessment are recommended as the
basis for consideration of cement augmentation. Integra-
tion within the total treatment schema is the primary
plan.
Discussion
The prognosis of patients with myeloma has improved
considerably over the last 15 years because of the
advances in Haematological Oncology. We therefore need
to become more proficient at treating the associated
medical/surgical complications related to the disease. One
such complication is one or more VCF’s of the spine.
Patients may present with significant spinal fracture pain
or neurological compromise. These signs and symptoms
may present at the time of the index procedure or when
there is a relapse of the disease. Essentially, myeloma
patients that present with spinal symptoms and signs need
to be assessed to establish the source and nature of their
pain and presence/absence of neurological compromise
and spinal instability.
Those that present with neurological compromise may
have spinal cord, cauda equina or nerve root compression.
It is imperative, in patients with neurological compromise,
to get not only an MRI scan with STIR and T1 weighted
images but also a CT scan (with soft tissue windowing) to
delineate whether it is bone or soft tissue compromising
the neurological structures. Soft tissue in the spinal canal
due to a myelomatous deposit is usually very sensitive to
treatment with chemotherapy/radiotherapy/steroids and
therefore the neural compression can be treated by these
modalities without the need for surgical decompression.
Ideally, one would like to avoid any instrumentation in
myeloma patients if possible because of the risk of sub-
sequent metalwork/deep spinal infection during periods
of immunocompromise. However, if there is significant
spinal cord compromise/cauda equina compression then
surgical decompression may be needed as an emergency
and an immediate spinal surgical consultation should be
sought on all such patients. Once the spinal cord/cauda
equine compression has been treated with steroids/che-
motherapy/radiotherapy, cement augmentation may be
needed to alleviate the pain associated with the fracture or
to restore spinal stability. It is uncommon for a myeloma
patient to present with neurological compromise because
of bony encroachment but if it occurs, radiotherapy/
chemotherapy/steroids will not be an effective treatment.
Surgery may be needed in this cohort of patients.
Patients who present with spinal pain, but no neurolo-
gical compromise should have an MRI scan performed
with STIR and T1 weighted images to detect any spinal
fractures. The T1 weighted images may be better than the
STIR images in highlighting the fracture line in vertebrae
infiltrated with a myelomatous deposit. If one has con-
cerns about the spinal stability because of a posterior wall
defect or pedicle/facet joint/pars involvement, then a CT
scan with sagittal and coronal reconstructions can be very
helpful. Patients can have quite significant bony defects
but still be structurally stable in an orthotic brace
80
.A
brace may be all that is needed in patients with a spinal
fracture if they can mobilise without significant pain. The
external orthosis will also keep the patients in the upright
posture (and potentially prevent the development of a
kyphotic deformity) while their fractures heal. Patients
who present with spinal pain and have a new diagnosis of
myeloma may need, depending on systemic symptoms, to
have their disease controlled with chemotherapy prior to
any consideration for cement augmentation. The che-
motherapy immune-compromises the patients and
therefore the correct timing of cement augmentation
should be a multi-disciplinary decision. Antibiotic pro-
phylaxis in the peri-operative period is strongly advised to
avoid infection. The orthotic brace can be a very useful
tool to control the pain to an acceptable level while the
disease is being treated with the first couple of cycles of
chemotherapy.
Another important aspect of the treatment in myeloma
patients involves bisphosphonate therapy. This drug
treatment clearly helps to stabilise the bone density in
patients with myeloma but, in addition may have a posi-
tive effect in producing an external scaffold of bone
around the vertebral bodies to confer them extra stability.
This external scaffold, which has been described as DISH
in prior publications
81
in patients with myeloma, may
decrease the need for spinal fixation in patients otherwise
thought to be at risk of spinal instability because of
involvement of all three bony spinal columns
57
.
Conclusion
TheprognosisofMMiscontinuallyimprovingdueto
medical advances. The treatment of myeloma with
chemo- immunotherapeutic agents and autologous stem
cell transplantation renders the patient immunocom-
promised for periods of time, exposing them to infec-
tion. Spinal fixation has been employed traditionally to
treat myeloma patients when decompression and sta-
bilisation were deemed to be essential. However, it is
well established that in situ instrumentation is at risk of
getting infected when the patients are in an immuno-
compromised state. If the metalwork gets infected, then
the consequences can be catastrophic. Cement aug-
mentation is a very effective way of stabilising the
anterior and middle spinal columns without the need for
metalwork fixation. It is an excellent way to relieve the
Kyriakou et al. Blood Cancer Journal (2019) 9:27 Page 8 of 10 27
Blood Cancer Journal
Content courtesy of Springer Nature, terms of use apply. Rights reserved
pain from a VCF. The myeloma spine treated with
bisphosphonates appears to produce an external scaffold
of bone that stabilises even the most moth-eaten spinal
elements once the disease process is under control. An
external orthosis can be very effective when trying to
achieve pain relief from a fracture. It also helps to
maintain the correct sagittal balance in patients with
multiplefractureswhiletheyhealorbeforetheyare
treated with cement augmentation. The development of
radiofrequency ablation in combination with cement
augmentation procedures is currently under investiga-
tion with encouraging results.
Author details
1
University College London and Northwick Park Hospitals, London, UK.
2
Royal
National Orthopedic Hospital, Stanmore, UK.
3
Moffitt Cancer Center, University
of South Florida, Tampa, FL, USA.
4
Roswell Park Cancer Center, Buffalo, NY, USA.
5
Klinikum Leverkusen, Leverkusen, Germany.
6
Karmanos Cancer Institute,
Detroit, MI, USA.
7
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
8
Massachusetts General Hospital, Boston, MA, USA.
9
Department of Laboratory
Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
10
Indiana University,
Indianapolis, IN, USA.
11
University of Athens School of Medicine, Athens,
Greece.
12
Mayo Clinic, Rochester, MN, USA.
13
Cedars-Sinai Samuel Oschin
Cancer Center, Los Angeles, CA, USA
Conflict of interest
The authors declare that they have no conflict of interest.
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Received: 3 June 2018 Revised: 9 September 2018 Accepted: 31 October
2018
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