What are the management options for back pain in a patient with multiple myeloma and vertebral compression fractures?

Management of Back Pain in Multiple Myeloma with Vertebral Compression Fractures

For patients with multiple myeloma and severe back pain due to vertebral compression fractures, balloon kyphoplasty is the treatment of choice when conventional pain management fails, providing pain relief in approximately 80% of cases (Grade 1A evidence). 1

Initial Pain Management Approach

Pharmacological Management

• Implement a stepwise approach based on pain severity:

  • Mild pain: Paracetamol (up to 1g four times daily)
  • Moderate pain: Oral tramadol or codeine
  • Severe pain: Fentanyl or buprenorphine patches or oral oxycodone (always with laxatives to prevent constipation)
  • For rapid relief: Subcutaneous opioid injections (oxycodone or morphine) 2

• For muscle spasm component:

  • Consider muscle relaxants such as clonazepam which can help with both muscle spasm and pain-associated anxiety 3

• For neuropathic pain components:

  • Add adjuvant medications such as gabapentin, pregabalin, lidocaine, oxcarbazepine, duloxetine, or amitriptyline 2

Bone-Modifying Agents

• Continue bisphosphonates (pamidronate or zoledronic acid) as part of ongoing treatment
• Monitor renal function before each infusion, particularly important with the patient's current Revlimid therapy
• For patients with renal impairment (CrCl 30-60 mL/min), reduce zoledronic acid dose to maximum 3mg or administer pamidronate via 4-hour infusion 1

Interventional Procedures

Vertebral Augmentation

• Balloon kyphoplasty is superior to vertebroplasty for the patient's T11 compression fracture with >90% height loss and metabolic activity 1, 4

• Benefits of kyphoplasty over vertebroplasty:

  • Lower rates of cement leakage (Grade 1A evidence)
  • Better long-term pain relief (statistically significant difference at 6 months and 1 year) 5
  • Potential to restore vertebral height (can restore up to 34% of height loss) 1

• Efficacy data:

  • Median VAS pain scores decrease from 9 to 1 after vertebral augmentation 6
  • Significant improvement in functional status and quality of life measures 7, 6

Radiation Therapy

• Consider low-dose radiation therapy (10-30 Gy) for the T11 vertebra with metabolic activity (SUV max 3.7)
• Particularly indicated given the increased metabolic activity within the lateral left vertebral body 1
• Use limited involved fields to minimize impact on potential future treatments 1

Surgical Intervention

• Given the >90% loss of height of T11, orthopedic consultation should be considered to evaluate for spinal instability
• Surgery may be indicated if there is evidence of spinal instability or neurological compromise 1

Monitoring and Follow-up

• Regular assessment of pain intensity and character
• Monitor for development of neurological symptoms that might indicate spinal cord compression
• Continue bone-modifying agents with appropriate monitoring of renal function
• Regular imaging follow-up to assess for new vertebral compression fractures

Potential Complications to Monitor

• Osteonecrosis of the jaw with continued bisphosphonate use
• Renal dysfunction with bisphosphonates, particularly in combination with Revlimid
• Venous thromboembolism risk with current Revlimid therapy (prophylactic anticoagulation recommended) 1
• Cement leakage with vertebral augmentation procedures (occurs in approximately 16% of cases but is usually asymptomatic) 7, 6

By implementing this comprehensive approach to managing back pain in this multiple myeloma patient with vertebral compression fractures, significant pain relief and improved quality of life can be achieved while continuing effective anti-myeloma therapy.