What is the follow-up specialty service for evaluation of compression of multiple vertebral bodies of uncertain age, possibly due to compression fracture or multiple myeloma?

From the Guidelines

For evaluation of multiple vertebral body compressions of uncertain age, I recommend referral to both a hematologist-oncologist and an orthopedic spine specialist or neurosurgeon. The hematologist-oncologist should perform a comprehensive workup for multiple myeloma, including serum protein electrophoresis, serum free light chain assay, complete blood count, comprehensive metabolic panel, and possibly a bone marrow biopsy 1. Concurrently, the spine specialist should evaluate the structural integrity of the vertebrae and determine if intervention such as vertebroplasty, kyphoplasty, or bracing is needed. Imaging studies should include MRI of the spine (with and without contrast) and a skeletal survey or low-dose whole-body CT scan. If multiple myeloma is confirmed, treatment typically involves combination chemotherapy regimens such as VRD (bortezomib, lenalidomide, dexamethasone) or KRd (carfilzomib, lenalidomide, dexamethasone), potentially followed by autologous stem cell transplantation in eligible patients. This dual-specialty approach is crucial because vertebral compression can result from both benign osteoporotic fractures and malignant processes like multiple myeloma, which presents with bone destruction in approximately 80% of cases. Prompt evaluation is important as untreated myeloma can lead to further bone damage, hypercalcemia, renal dysfunction, and bone marrow failure.

Some key points to consider in the evaluation and management of multiple vertebral body compressions include:

• The importance of a comprehensive workup for multiple myeloma, including serum protein electrophoresis, serum free light chain assay, and bone marrow biopsy 1
• The need for imaging studies, including MRI of the spine and a skeletal survey or low-dose whole-body CT scan, to evaluate the structural integrity of the vertebrae and detect any potential lesions 1
• The potential for intervention, such as vertebroplasty, kyphoplasty, or bracing, to stabilize the spine and alleviate pain 1
• The importance of prompt evaluation and treatment, as untreated myeloma can lead to further bone damage, hypercalcemia, renal dysfunction, and bone marrow failure 1

Overall, a dual-specialty approach, combining the expertise of a hematologist-oncologist and an orthopedic spine specialist or neurosurgeon, is essential for the evaluation and management of multiple vertebral body compressions of uncertain age.

From the Research

Evaluation of Compression of Multiple Vertebral Bodies

• The patient's condition may be due to vertebral compression fractures, which are the most common complication of osteoporosis, with 700,000 cases reported every year in the United States 2.
• Vertebral compression fractures typically present with abrupt-onset low back pain with or without a history of trauma, although more than two-thirds are detected incidentally 2.
• Diagnosis is confirmed using plain radiographs, while computed tomography and magnetic resonance imaging may be required to evaluate for a malignant cause or if there are neurological deficits on examination 2.
• Magnetic resonance imaging is also the modality of choice to determine if the fracture is acute vs chronic in nature 2.

Differential Diagnosis

• Multiple myeloma is another possible cause of compression of multiple vertebral bodies, with up to 90% of patients with multiple myeloma developing bone lesions 3.
• The "gold standard" for imaging myeloma bone lesions is the metastatic bone survey, but plain radiographs are relatively insensitive and can only demonstrate lytic disease when 30% of trabecular bone loss has occurred 3.
• Computerized tomography (CT) scanning, magnetic resonance imaging (MRI), and positron emission tomography (PET) scans can be used to evaluate the extent of bone disease in patients with myeloma 3.

Management

• Patients with vertebral compression fractures can be managed with a combination of nonsurgical modalities including medications, bracing, and physical therapy, although when indicated, kyphoplasty or vertebroplasty may be considered to provide symptom relief 2, 4.
• Treatment of myeloma bone disease involves treatment of the underlying malignancy and its manifestations, including bisphosphonate therapy, kyphoplasty, vertebroplasty, radiation therapy, and novel agents to suppress osteoclastic bone resorption 3.
• The temporal clustering of numerous fractures (cluster phenomenon) is a cause of transient severe disability in patients who have profound osteopenia, and may be precipitated by exacerbation of an intercurrent illness or by an associated obligate increase in glucocorticoid medication in a patient with preexisting severe osteopenia 5.

Imaging

• Magnetic resonance imaging (MRI) is important in evaluating bone marrow infiltration patterns in multiple myeloma, and can help discriminate between normal marrow reconversion and malignant infiltration 6.
• A "salt and pepper" infiltration of the spine seen on MRI can be indicative of non-secretory multiple myeloma, a rare variant of multiple myeloma 6.