How do you manage a compression fracture due to lymphoma?

Management of Compression Fractures Due to Lymphoma

Vertebral augmentation procedures are strongly recommended for patients with compression fractures due to lymphoma to reduce pain and improve quality of life. 1

Initial Assessment and Diagnosis

• Obtain MRI of the entire spine (sagittal T1-weighted) for patients with new onset back pain and suspected lymphoma involvement 1
• CT imaging may be necessary if MRI is contraindicated 2
• Establish definitive diagnosis through histologic or cytologic methods before initiating treatment 1
• Evaluate for spinal cord compression, which requires urgent intervention

Medical Management

Pain Control

• Start with strong opioids for severe pain 1
• Consider parenteral morphine or transmucosal fentanyl citrate for breakthrough pain 1
• Add corticosteroids (high-dose dexamethasone at 16 mg/day) if there is evidence of spinal cord compression or significant edema 1, 2

Bone-Directed Therapy

• Bisphosphonates are recommended in addition to other treatments for pain relief 1
  • Zoledronic acid is preferred (4 mg via 15-min infusion monthly) 1
  • Reduce dose to maximum 3 mg in patients with moderate renal impairment (creatinine clearance 30-60 mL/min) 1
• Calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation 2

Interventional Management

Vertebral Augmentation

• Vertebral augmentation procedures (vertebroplasty or kyphoplasty) are strongly recommended for pain reduction 1
• Consider these procedures when:
  • Pain is not adequately controlled with analgesics 1
  • Patient experiences significant side effects from analgesics 1
  • Medical therapy has been tried for at least 6 weeks 1

Radiation Therapy

• External beam radiation therapy is recommended for pain relief from bone metastases 1
  • A single fraction of 8 Gy is as effective as higher fractionated doses 1
• For lymphoma specifically, radiation therapy is particularly effective due to the radiosensitive nature of the disease 3, 4

Surgical Management

• Surgical fixation is recommended for:
  • Painful bone metastases to long/weight-bearing bones 1
  • Well-defined lytic lesions involving >50% of the cortex 1
  • Expected survival >4 weeks with satisfactory health status 1
• For spinal cord compression with good performance status, neurosurgical consultation should be sought immediately 1
  • If appropriate, surgery should be performed followed by radiation therapy 1, 2

Special Considerations for Lymphoma

• Lymphoma is highly radiosensitive, making radiation therapy particularly effective 3, 4
• Chemotherapy is the primary treatment for the underlying lymphoma and should be initiated promptly 3
• Caution with high-dose radiation (>5000 rad) as it may increase fracture risk without improving local control 5
• Monitor for disease progression as lymphoma can present with both epidural masses and pathologic fractures 6

Follow-up Care

• Regular monitoring of neurological status during and after treatment 2
• Assessment of treatment response through pain relief and neurological function 2
• Consider physical therapy with focus on lumbar stabilization once pain is controlled 2
• Early introduction of physical training and muscle strengthening for rehabilitation 2

Cautions and Pitfalls

• Delay in diagnosis and treatment leads to worse neurological outcomes 2
• Radiation doses above 5000 rad may increase fracture risk without improving disease control 5
• Vertebral augmentation is contraindicated in active systemic infection or uncorrectable bleeding diathesis 1
• Careful monitoring for hypercalcemia, which can result from excessive bone resorption 1