What is the treatment for myelomalacia spine?

Treatment for Myelomalacia of the Spine

Myelomalacia of the spine requires immediate treatment with radiation therapy (10-30 Gy) for palliative management, along with bisphosphonates to prevent further bone deterioration and surgical intervention for cases with spinal cord compression or vertebral instability.

Understanding Myelomalacia

Myelomalacia refers to the softening of the spinal cord, which in the context of multiple myeloma is typically caused by:

• Vertebral compression from lytic bone lesions
• Spinal cord compression from tumor infiltration
• Vascular compromise leading to ischemic damage

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Imaging: WBLD-CT (Whole-body, low-dose computed tomography) is the preferred method for detecting lytic lesions 1
• MRI: Recommended if spinal cord compression is suspected 1
• Skeletal survey: Can be used if WBLD-CT is unavailable 1

Treatment Algorithm

1. Immediate Management for Spinal Cord Compression

• High-dose dexamethasone: Start immediately when spinal cord compression is suspected 1
• Emergency radiation therapy: Should be initiated as soon as possible 1
• Surgical decompression: Required when bone fragments are present within the spinal canal 1

2. Radiation Therapy

• Dosage: Low-dose radiation therapy (10-30 Gy) 1
• Application: For palliative treatment of:
  • Uncontrolled pain
  • Impending pathologic fracture
  • Impending or actual spinal cord compression 1
• Technique: Limited involved fields should be used to minimize effects on potential stem cell harvest 1
• Fractionation: Moderately fractionated courses of 20-25 Gy in 8-10 fractions are generally preferred over higher doses to limit toxicity 1

3. Bone-Targeting Agents

• Bisphosphonates: Recommended for all patients with symptomatic multiple myeloma regardless of documented bone disease 1

  • Options: Zoledronic acid or pamidronate 1
  • Duration: Continue for up to 2 years; continuation beyond 2 years should be based on clinical judgment 1
  • Frequency: Monthly or every 3 months depending on individual patient criteria and response to therapy 1
  • Special consideration: Pamidronate may be preferred over zoledronic acid due to lower risk of osteonecrosis of the jaw 1

• Denosumab: Alternative to bisphosphonates, preferred in patients with renal disease 1

4. Surgical Intervention

• Indications:

  • Pathological fractures
  • Risk of fracture in weight-bearing bones
  • Vertebral column instability
  • Bone fragments within the spinal canal 1

• Procedures:

  • Vertebroplasty or kyphoplasty for symptomatic vertebral compression fractures 1
  • Orthopedic consultation should be obtained for impending or actual fractures 1

5. Systemic Therapy for Underlying Multiple Myeloma

• Treatment of the underlying multiple myeloma should not be delayed for radiation therapy and can often be given concurrently 1
• Patients should be carefully monitored for toxicities when receiving concurrent treatments 1

Monitoring and Follow-up

• Annual skeletal survey for follow-up of bone disease 1
• Regular monitoring of renal function in patients on bisphosphonates 1
• Monitoring for osteonecrosis of the jaw in all patients receiving bone-modifying agents 1

Potential Complications and Management

• Hypercalcemia: Treat with hydration, bisphosphonates, steroids, and/or calcitonin 1
• Renal dysfunction: Maintain hydration and avoid NSAIDs 1
• Infections: Consider prophylaxis with antivirals, particularly in patients receiving proteasome inhibitors 1

Important Caveats

• Careful planning of radiation fields and techniques is crucial to minimize toxicity to the spinal cord and adjacent organs, especially since patients may require multiple treatments during the disease course 1
• Avoid NSAIDs and intravenous contrast media in patients with renal impairment 1
• Baseline dental examination is recommended before starting bisphosphonates or denosumab 1

By following this comprehensive approach to treating myelomalacia in multiple myeloma patients, clinicians can effectively manage symptoms, prevent further deterioration, and improve quality of life.