SICOT Global Network for Electronic Learning - SIGNEL
Case of the Month
National Scientific and Practical Center for Traumatology and Orthopaedics, Minsk, Belarus
History
A 36-year-old man suffered from pain in the lumbar spine, periodically radiating to both legs. The pain was present for about 4 months, then spontaneously resolved for 4 months and resumed again after exercise. Palpation of the lumbar spine was painful in the projection of the L3 vertebra. There was no neurological deficit. X-ray of the lumbar spine in 2 views showed changes in the shape of the L3 vertebra. A complete blood count revealed an increase in ESR to 18 mm per hour.
Q. What is your provisional diagnosis for this patient?
Diagnosis
Pathological fracture of L3 vertebra of unknown aetiology.
Q. What would be your next step in the management of this patient?
Immediate surgical stabilization
Further investigations – MRI/CT Scan/Bone Scan/Sternal puncture
Observation and conservative treatment
Fig. 1: MRI examination of the lumbar spine
Q. What are your thoughts on the MRI of the lumbar spine?
MRI examination of the lumbar spine has revealed a pathological formation of the L3 vertebra with the presence of a soft tissue component, and stenosis of the spinal canal.
Fig. 2: X-ray computed tomography of the L3
Q. What do you see on the CT scan?
X-ray computed tomography of the L3 vertebra revealed involvement of the arch and the spinous process of the L3 vertebra in the pathological process. Bone scan (osteoscintigraphy) showed a moderate accumulation of Technetium-99m in the L3 vertebra. Sternal puncture revealed no pathology.
Q. How will you manage this further?
Open biopsy
Оpen express biopsy and decompressive-stabilizing intervention
Conservative treatment
Treatment
An open express biopsy of the pathological focus in the body of the L3 vertebra was performed. It revealed plasmacytoma. Clinical diagnosis: pathological L3 fracture caused by solitary myeloma.
Surgical treatment – Vertebroplasty of L3 body, posterolateral decompression of L3, cytoreductive removal of tumor L3, transpedicular fixation of L2-L4 vertebrae.
In the postoperative period – radiotherapy, chemotherapy according to protocols.
Observation of the patient – pain completely resolved, no neurological disorders, no disease recurrence for 2.5 years.
Fig. 3: X-ray computed tomography of the L3 after surgical treatment
Discussion
In many cases, vertebral biopsy is warranted to guide treatment [1].
As a result of vertebral lesions, patients with myeloma suffer from pain, permanent deformity, kyphosis, walking impairment, permanent disability or paralysis [2]. Treatment of solitary plasmocytoma often requires surgery in combination with radiotherapy [1, 2].
Vertebral compression fractures caused by multiple myeloma or plasmacytomas can be effectively treated by vertebroplasty. Vertebroplasty is associated with early clinical improvement of pain and function and can be maintained after a long follow-up without major procedure-related complications [3].
In case radiotherapy is planned, it should be performed after vertebroplasty or kyphoplasty [2].
- Rodallec M. H., Feydy A., Larousserie F. et al. Diagnostic Imaging of Solitary Tumors of the Spine: What to Do and Say 2008 RadioGraphics, 28, 1019-1041
- Tosi P. Diagnosis and Treatment of Bone Disease in Multiple Myeloma: Spotlight on Spinal Involvement // Hindawi Publishing Corporation Scientifica Volume 2013, Article ID 104546, 12 pages http://dx.doi.org/10.1155/2013/104546
- Ramos L., de Las Heras J.A., Sanchez S., et al. Medium-term results of percutaneous vertebroplasty in multiple myeloma. Eur J Haematol 2006;77:7–13
