Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e356-e365
World Neurosurgery

Original Article
Evaluation of the Relevance of Surgery in Patients with Multiple Myeloma Harboring Symptomatic Spinal Involvement: A Retrospective Case Series

https://doi.org/10.1016/j.wneu.2018.02.184Get rights and content

Highlights

  • The role of surgery in the management of myeloma-related spinal involvement is controversial.

  • We retrospectively assessed the surgical success of our procedures, considering pain relief, ability to walk, spinal stability, and morbidity.

  • We reported rewarding functional results, with acceptable morbidity.

  • Surgery for multiple myeloma vertebral lesions seems to be a valuable option for carefully selected patients.

Background

Multiple myeloma spinal involvement can lead to bone fractures and neurologic impairment that can severely alter quality of life. The role of surgery is controversial, given its high morbidity, and the lack of evidence. We hereby aim to evaluate efficacy and safety of surgery in the management of symptomatic spinal lesions in patients with multiple myeloma.

Methods

We included all patients operated on for a myeloma-related spinal lesion in our institution between 2007 and 2015. Demographic, clinical, and surgical data were collected as well as hematologic profiles. We retrospectively assessed the surgical success of the procedures, if at 3 months the patient fulfilled the following 4 criteria: pain relief, ability to walk, spinal stability, and no relevant morbidity.

Results

Thirty-six men and 19 women, with a median age of 62 years, were included. Seventeen patients underwent an emergency intervention, whereas 38 patients underwent elective surgery. At 3 months, 88.2% and 96.1%, respectively, of patients experienced pain relief and were able to walk. Spinal stability was considered satisfactory for 94.1% of patients. We reported 8 major complications in 8 patients. Altogether, 34 patients (61.8%) fulfilled all criteria for surgical success. An International Staging System score of 1 and the absence of previous chemotherapy were significantly associated with surgical success.

Conclusions

Management of myeloma-related spine lesions requires a multidisciplinary approach. Surgery rapidly provides both decompression and stabilization. Using a strict patient-specific evaluation, we reported rewarding functional results, with acceptable morbidity. Surgery for multiple myeloma vertebral lesions seems to be a valuable option for carefully selected patients.

Introduction

Multiple myeloma is a malignant hematologic disorder, in which plasma cells proliferate in the bone marrow, leading to osteolytic bone lesions, commonly involving the spine. It accounts for approximately 1.8% of cancers, and 13% of hematologic malignancies,1, 2 and is the most frequent primary cancer of the spine.3 With a median age of patients at diagnosis of 69 years, myeloma is considered an age-related disease and, given the aging population trend, the current incidence of 6.6 cases per 100 000 is likely to increase in the future.1 The outcome remains highly heterogeneous with a 5-year survival of approximately 50% (SEER [Surveillance Epidemiology and End Results] data).4, 5

Bone disease is typically characterized by numerous well-circumscribed focal lesions, as well as diffuse demineralization, which is aggravated/worsened by steroids.6, 7, 8, 9, 10, 11, 12, 13, 14, 15 Periosteal infiltration causes severe pain, often requiring morphine.10 Vertebral involvement is frequent and leads to spinal instability, pathologic fractures, and epidural involvement.7, 8, 10, 16, 17, 18, 19, 20 All these factors imply a high risk of neurologic complications,10, 17, 21, 22, 23, 24, 25, 26, 27, 28 and substantially reduce independence and quality of life.29, 30, 31, 32, 33

The treatment of myeloma is complex and requires a truly multidisciplinary approach, especially when considering spine lesions.10, 24, 32, 34 Although chemotherapy in combination with bisphosphonates aims to reduce plasma-cell proliferation and bone destruction,9, 19, 34, 35, 36, 37, 38 there is still no consensus regarding the role of local treatments such as radiotherapy, vertebroplasty/kyphoplasty, or surgery. Unlike spinal metastases, the surgical management of spinal deposits in multiple myeloma is not well documented. Although some indications are commonly accepted, its role remains controversial, especially in the absence of neurologic impairment. Surgery may be associated with increased morbidity, in such frail patients who harbor poor bone quality and have a high risk of infection inherent in their disease.34, 39, 40 It is therefore crucial that the iatrogenic potential of surgery does not outweigh the expected benefits.

In this study, we aimed to evaluate both efficacy and safety of surgery for the management of symptomatic spinal lesions in patients with multiple myeloma.

Section snippets

Inclusion Criteria

Using our local medical coding system, we reviewed the medical records of the 724 patients who underwent surgery for the treatment of a spinal tumor in the Lille University Hospital between January 2007 and December 2015. We excluded patients who underwent surgery for a spine metastasis from solid cancer as well as patients with solitary bone plasmocytoma or other hematologic disease. In total, 55 patients underwent surgery for a myeloma-related spinal lesion during the study period.

Data Collection

We

Population

A total of 55 patients were included in this retrospective study. The number of patients operated on annually increased significantly during the study period (P = 0.009) (Figure 1). The main demographics are summarized in Table 2. There were 36 men and 19 women in our cohort and the median age at surgery was 62 years (interquartile range, 54–68). The KPS was ≥80% in 33 patients and <80% in 20 patients. KPS could be low because of acute neurologic impairment. Thus, the operability was a

Population

Our study is, to the best of our knowledge, the largest surgical series of myeloma spinal lesions. Because our patients had been selected and considered eligible for surgery, they were younger than the general population of patients with myeloma1 and had mostly favorable KPS and ISS scores. Coherently, most of our patients received intensive medical treatment, including autologous stem-cell transplantation. The other demographic characteristics matched the general population with myeloma. All

Conclusions

The management of myeloma spine lesions is complex and requires a truly multidisciplinary effort. Surgery is the only therapeutic option that can rapidly provide both decompression and stabilization of the affected vertebrae. Using a strict and individual evaluation, we reported rewarding functional results, with an acceptable morbidity. Therefore, offering surgery for multiple myeloma–related vertebral lesions seems to be a valuable option, for carefully selected patients.

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  • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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