Optimizing the management of patients with spinal myeloma disease

Abstract

Summary Myeloma is one of the most common malignancies that results in osteolytic lesions of the spine. Complications, including pathological fractures of the vertebrae and spinal cord compression, may cause severe pain, deformity and neurological sequelae. They may also have significant consequences for quality of life and prognosis for patients. For patients with known or newly diagnosed myeloma presenting with persistent back or radicular pain/weakness, early diagnosis of spinal myeloma disease is therefore essential to treat and prevent further deterioration. Magnetic resonance imaging is the initial imaging modality of choice for the evaluation of spinal disease. Treatment of the underlying malignancy with systemic chemotherapy together with supportive bisphosphonate treatment reduces further vertebral damage. Additional interventions such as cement augmentation, radiotherapy, or surgery are often necessary to prevent, treat and control spinal complications. However, optimal management is dependent on the individual nature of the spinal involvement and requires careful assessment and appropriate intervention throughout. This article reviews the treatment and management options for spinal myeloma disease and highlights the value of defined pathways to enable the proper management of patients affected by it.

Managing the cervical spine in multiple myeloma patients

“…Magnetic Resonance Imaging (MRI) scanning is a highly sensitive imaging modality when determining spinal involvement in MM, and assessing the response to treatment . As a staging technique, whole body MRI has a better diagnostic profile for early myeloma compared with whole body CT scanning, primarily due to the display of marrow replacement by neoplastic cells on MRI . MRI will accurately identify the subtle edema of fragility fractures, which are more likely to occur in patients with myeloma, but these are not as prevalent in the cervical spine.…”

“…While MRI delineates tumor extension adequately, fat and sclerotic components, sometimes seen with myeloma, can result in signal loss and may be mistaken for a benign lesion . Bone marrow reconversion and peritumoral edema on short tau inversion recovery (STIR) sequencing may lead to overestimation of tumor extent . With an advanced disease, the absence of signals from the cortical bone and calcium is a hindrance in MRI and is best assessed with CT …”

“…While side effects are well known, potential for falls is significant given the associated dizziness and resultant kyphotic deformity . Neck pain with facet loading can be treated with targeted facet joint injections …”

“…The algorithmic approach for managing myeloma, as outlined by the UK Spinal Myeloma Working Group, is relevant for the management of cervical spine myeloma …”

“…31 As a staging technique, whole body MRI has a better diagnostic profile for early myeloma compared with whole body CT scanning, primarily due to the display of marrow replacement by neoplastic cells on MRI. 32,33 MRI will accurately identify the subtle edema of fragility fractures, which are more likely to occur in patients with myeloma, but these are not as prevalent in the cervical spine. While MRI delineates tumor extension adequately, FIGURE 1 A, Index sagittal CT scan of a myeloma patient.…”