Surgery Improves Pain and Quality of Life in Multiple Myeloma Patients with Symptomatic Osteolytic Spinal Lesions

Research Article

Austin Orthop. 2016; 1(1): 1002.

Surgery Improves Pain and Quality of Life in Multiple Myeloma Patients with Symptomatic Osteolytic Spinal Lesions

Syrimpeis VN¹*, Korovessis P¹, ZikosP² and Peter Fennema³

¹Orthopaedics Department, General Hospital of Patras, Greece

²Hematology Departments, General Hospital of Patras, Greece

³AMR Advanced Medical Research GmbH, Switzerland

*Corresponding author: Syrimpeis VN, Orthopaedics Department, General Hospital of Patras, Greece

Received: July 19, 2015; Accepted: August 29, 2016; Published: September 01, 2016


Study Design: A prospective study.

Objective: To present the functional outcome and the survival of 21 consecutive selected Multiple Myeloma (MM) patients who underwent 25 surgeries for symptomatic vertebral body osteolysis.

Summary of Background Data: Percutaneous augmentation with polymethyl methacrylate in patients with osteoporotic vertebral body fractures safely reduces the vertebral body deformity and pain. There are few shortterm studies reporting functional outcome and survival, following surgery for osteolytic vertebral body lesions in MM patients, with or without neurological impairment.

Methods: Between December 2004 and May 2012, 25 wide spectrum surgeries including percutaneous augmentation, hybrid fixation and circumferential decompression were performed for symptomatic vertebral body osteolysis in 21 selected patients with MM. Tomita osteolysis classification, Karnofsky disability scale; ASIA neurological impairment scale and VAS pain scale were used. Survival analysis was performed.

Results: All patients were followed for a minimum of 6 months postoperatively. Karnofsky Index improved from 66%±20% preoperatively to 81.3%±15%, one month and 83%±10% one year postoperatively. VAS score significantly reduced in all patients from 7.08±2 preoperatively to 3.35±1.5 at the latest evaluation. One patient with ASIA grades D and 2 with ASIA grades C improved postoperatively to ASIA E. The one-year survival from index diagnosis was 85.2% (95% CI, 60.6% - 96.0%), while it dropped to 55.4% (29.4% - 75.1%) five-year postoperatively. Τhe one-year survival rate from index surgery was 65.9% (95% CI, 38.8% - 83.2%), and dropped to 33.5% (95% CI, 11.1% - 58.0%) five-year post operation.

Conclusions: There are several modalities of surgery for symptomatic osteolytic vertebral body lesions in MM patients. Surgery was proved a safe procedure with few complications it reduced pain and improved quality of life. Together with hematological and radiation therapy it may increase the survival of MM patients.

Keywords: Multiple Myeloma; Spinal Lesions; Spine Surgery; Augmentation; Decompression; Spine; Minimal Invasive Surgery; Stabilization; Kyphoplasty; Tumor


Multiple Myeloma (MM) is a systemic neoplasm of plasma cells that affects 1-4 per 100,000 people per year and is commonly associated with bone pain, usually due to spinal and rib osteolyses, in 70% of this kind of patients [1-4]. Skeletal osteolyses are the most frequent cause of morbidity and mortality in patients affected by this pathology [5].

Spinal involvement can be the initial clinical presentation of the disease in 34-64% of the MM patients, leading often to intractable pain and/or neurological complications due to spinal cord or cauda compression [6,7]. In the one third of the patients, MM is diagnosed after a pathological spinal fracture has occurred [8], moreover new vertebral body fractures occur in approximately 15-30% of patients with MM annually [5].

Recent advances in therapeutic approaches, such as autologous stem cell transplantation, radiotherapy and chemotherapy, bracing and surgery in certain cases, helps towards lessening the occurrence and severity of adverse effects of this disease, as well as managing associated complications. [7,9-14]. Although medical treatments & radiation help towards slowing down the natural history of MM [5], they do not correct any structural vertebral destruction that may have already been occurred, either as osteolysis or as a fracture and wedge deformity in up to 70% of all patients with MM [15-17]. In vertebral body osteolyses and/or vertebral body fractures, the main goal of surgical intervention is pain relief, reduction of angular deformity for prevention of potential neural element compression and spinal canal decompression. In the last few years, percutaneous Minimal Invasive Surgery (MIS), vertebral augmentation techniques such as Vertebroplasty (VP), Balloon Kyphoplasty (BK) and KIVA [18], are well tolerated and drastically decrease pain while simultaneously improve patient’s quality of life [15,16,17,19]. Radiofrequencytargeted vertebral augmentation was recently developed to address potential adverse issues reported with VP and BK [2,20,21,22]. However, in patients with vertebral body osteolyses with involvement of the posterior vertebral body wall some authors have raised concerns regarding the high leakage rates associated with low viscosity polymethylmethacrylate (PMMA) bone cement [23,24,25,26].

In cases of pathologic vertebral body fracture associated spinal canal encroachment with or potential for neurological involvement, open decompressive surgeries with stabilization may be indicated, however these are depending on the general patient’s condition which in MM patients is often poor.

Survival after MM is highly variable; however, recent studies of various drug therapies have led to promising outcomes and reported survival beyond 10 years [12-13].

Although early clinical results are promising [27], there is no evidence regarding long-term effect of palliative surgery in MM patients with symptomatic vertebral osteolysis.

The aim of this prospective study is to present the functional outcome and survival rates following surgical treatment in 21 consecutive selected MM patients, who underwent a total of 25 surgeries, by a single senior orthopedic spine surgeon, in one tertiary institution and to review the relative literature.

Materials and Methods

Twenty-one consecutive selected patients (7 women, 14 men) suffering from MM with established spinal involvement and associated intractable pain, who were surgically treated between 2004 and 2012 in the author’s Orthopaedic institution by a single spine surgeon (Table 1), were prospectively evaluated. Institutional Review Board (IRB) approval and patient informed consent was obtained in all patients. The average ±SD age of the patients at the index surgery was 70±21, range 49-90 years. All patients were managed by a multidisciplinary team including hematologist, radiotherapist and orthopaedic spine surgeon. Systemic therapy (chemotherapy & irradiation) was administrated in 19/21 patients before and/or after surgery. Bone marrow transplantation before surgery had been done in 1/21 patient. Preoperative patient evaluation included a complete physical examination, plain roentgenograms, CT-scan, Magnetic Resonance Imaging (MRI) and hematological evaluation. The Tomita classification [31] was used to grade the extension of vertebral body osteolytic lesions, (Table1). The VAS (0-10 scale) [28] and the ASIA neurological classification [29] were used for evaluation of patients’ pain level and neurological function. The quality of life was evaluated with the Karnofsky Index [30].All values are expressed as average ±SD. The inclusion criteria and indications for surgical intervention were MM or solitary spinal plasmocytoma with symptomatic spinal involvement (painful osteolysis ± spinal fracture, neurological impairment or potential or progressive neurological impairment due to vertebral body fracture), intractable spinal pain resistant to conservative treatment (pain killers, brace, etc). The diagnosis of MM was already preoperatively established in 17/25 (68%) cases, while in the remaining 8/25 (32%) cases, the diagnosis was first disclosed from the intra-operatively taken biopsy. Our surgical strategy was as follows: Patients neurologically intact and osteolysis in ≥1 non-contiguous vertebral body (-ies) were treated with vertebral augmentation solely; in patients with multilevel contiguous cervical spine involvement vertebrectomy, mesh cage plus posterior fixation was made; patients with neurologic impairment were treated with posterior MIS reduction, pedicle screw stabilization plus vertebral body augmentation; patients with posterior cord/cauda compression (posterior spinal elements involvement) were treated via wide laminectomy and posterior pedicle screw fixation. Patient survival, using all-cause mortality as event of interest, was estimated with the Kaplan-Meier method [32].