Case Report - (2020) Volume 9, Issue 4
Received: 06-Jul-2020
Published:
21-Jul-2020
, DOI: 10.37421/2165-7939.2020.9.449
Citation: Natan Silver and Yair Barzilay. “Turning a Challenge
into an Advantage: A Technical Note on Kyphoplasty for Multiple Myeloma.” J
Spine 9 (2020): 449. DOI: 10.37421/jsp.2020.9.449
Copyright: © 2020 Silver N, et al. This is an open-access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited.
Kyphoplasty, a procedure first described in 2001 for the treatment of osteoporotic Vertebral Compression Fractures (VCFs) has since been used successfully for pathological vertebral compression fractures, including those caused by multiple myeloma. Whilst the evidence base for kyphoplasty remains incomplete, there is a general consensus that it is safe and significantly reduces pain in up to 84% of patients in whom nonsurgical management has failed.
Kyphoplasty • Clinical indications • Pathology
Although kyphoplasty has a range of clinical indications, it also has recognised contra-indications [1-9]. The structural integrity of the affected vertebra must be considered in advance in order to enable a successful procedure. Until recently posterior wall defects were considered to be a contraindication [10], due to the risk of cement travelling posteriorly and occupying the spinal canal, but several studies have proven that kyphoplasty can be performed safely even with posterior wall defects, as long as appropriate technique is used [11-13]. In cases of endplate compromise kyphoplasty can be challenging, as cement leakage into the disk space can occur, increasing the risk of adjacent level fracture. This case report describes the utilization of endplate defects to improve the augmentation of two adjacent vertebrae affected by multiple myeloma lesions.
A 78-year-old man presented to the emergency department with intractable upper back pain, including night pain, and inability to mobilize due to pain. He had no significant medical background. On physical examination there was mid-thoracic midline tenderness and inability to change position in bed due to pain. Neurological examination was normal. Complete blood count and coagulation profile were normal, biochemistry revealed a slightly elevated creatinine of 1.22 mg/dL with normal calcium levels. Inflammatory markers were normal. Thoracic spine radiographs (Figure 1) demonstrated a compression fracture of T9. Computed tomography of the thoracolumbar spine (Figure 2) revealed lytic lesions in T8 and 9 with a pathologic compression fracture of T9. Defects of the T8 lower endplate and T9 upper endplate, as well as the T9 posterior wall, were noted. A very small lytic lesion was also observed in T7-not large enough to warrant intervention or cause concern of adjacent level fracture following treatment of T8.
Figure 1. Compressed T9 body with suspicion of lytic appearance.
Figure 2. Endplate defects creating continuity between T8 and T9 vertebral bodies: Posterior wall defect of T9 also evident.
Balloon kyphoplasty of T8 and T9, combined with biopsy, was planned in order to obtain a diagnosis, treat intractable pain, and allow early mobilisation. The patient was operated on under general anaesthesia in the prone position on a spinal operating table (four poster frame). During cementation of T9 under fluoroscopy, the cement was observed to be travelling posteriorly, towards the spinal canal (Figure 3a), therefore cementation of T9 was ceased. Kyphoplasty of T8 was performed with introducers aimed at the lower half of the vertebral body. Taking advantage of the large cortical defects of the inferior T8 endplate and the superior T9 endplate, approximately 6 ml of cement was injected into the bottom of T8 with the cement travelling inferiorly through the endplate defects and into the superior part of T9 (Figures 3b-3d). This enabled cement augmentation of both vertebrae simultaneously with the T8 cement mass resting on the cured cement mass of T9. Stability was demonstrated by postoperative standing radiographs (Figure 4). Post-operatively the patient’s pain improved from VAS 9 to VAS 2 and this result was maintained at outpatient follow up. The pathology report demonstrated multiple myeloma and the patient were referred to hematology day care service. A CT performed at 18 months post-operatively (Figure 5) demonstrated bridging bone and no compromise of the cement mass. No progression was seen of the T7 lesion, nor any sign of adjacent level fracture.
Figure 3. (a): Cement from T9 has travelled posteriorly towards the spinal canal-at this point cementation of T9 was ceased. (b): Introducer of T8 directed inferiorly towards the endplate defect. (c): Cement from T8 body begins to move inferiorly and through the endplate defect. (d): Cement passes through both endplate defects, crossing the disc space and coming to rest on the cured cement mass of T9.
Figure 4. Bridging bone (Left).
Figure 5. Bridging bone (Right).
Kyphoplasty has been shown to provide pain relief for patients with pathological compression fractures secondary to multiple myeloma. In this patient the myeloma involved adjacent endplates creating a space which was utilized to create continuity of the cement masses. This helped to improve stability, allowing immediate mobilization and better conditions for fracture healing. We conclude that endplate defects, rather than impeding cementation, can potentially be used as a tool for more effective augmentation.
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