This patients pain is due to an acute compression fracture (Figure 2) and the resultant edema and inflammation. The MRI findings are typical of an acute fracture and have also ruled out an associated soft tissue mass (plasmacytoma) and cord compression; thus, neurosurgical decompression is not indicated. Likewise, this patients symptoms are due to mechanical consequences of an acute fracture, and radiotherapy is not likely to relieve these symptoms. Vertebroplasty or kyphoplasty are minimally invasive spinal procedures that stabilize the fractured vertebral body and can provide rapid pain relief in many cases. The neurologic symptoms described predated the onset of back pain and are common side effects of thalidomide and vincristine, 2 commonly used therapies for MM. A compression fracture in a patient with previously documented skeletal disease is not necessarily evidence of myeloma progression, and other testing to reassess MM should be undertaken prior to switching therapy. Bisphosphonate therapy is considered standard therapy for MM patients with lytic bone disease, as randomized studies have shown that bisphosphonates are useful in preventing compression fractures and other skeletal complications of MM. This patient should have already been on either monthly zoledronic acid or pamidronate from the time of diagnosis; these drugs do not have any role in the management of an acute pathologic fracture.
- Evaluation for vertebroplasty or kyphoplasty.
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