Vertebroplasty for pain relief and spinal stabilization in multiple myeloma

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adults with neoplastic vertebral fractures

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adults with Neoplastic Vertebral Fractures features evidence-based recommendations for diagnosing and treating adult patients with neoplastic vertebral fractures. The guideline is intended to reflect contemporary treatment concepts for neoplastic vertebral fractures as reflected in the highest quality clinical literature available on this subject as of October 2020.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with neoplastic vertebral fractures. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of NASS' Clinical Practice Guidelines Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with a medical librarian. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Twenty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with neoplastic vertebral fractures. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at http://www.spine.org/guidelines.

Appropriate use criteria for neoplastic compression fractures

BACKGROUND CONTEXT

Clinical outcomes are directly related to patient selection and treatment indications for improved quality of life. With emphasis on quality and value, it is essential that treatment recommendations are optimized.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) is to determine the appropriate (ie, reasonable) multidisciplinary treatment recommendations for patients with metastatic neoplastic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Systematic Review OUTCOME MEASURES: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain," or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of neoplastic vertebral fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC work group determined key modifiers and adopted the standard definitions developed by CPG, with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Based on the literature, provider experience, and group discussion, each scenario was scored on a 9-point scale on 2 separate occasions, once without discussion and then a second time following discussion based on the initial responses. The median rating for each scenario was then used to determine if indications were rarely appropriate (1-3), uncertain / maybe appropriate (4-6), or appropriate (7-9). Consensus was not mandatory.

RESULTS

Medical management was essentially always appropriate. Radiation therapy was appropriate 50% of the time and uncertain otherwise, and directly related to radiosensitivity of the tumor. Ablation was never rated appropriate with agreement, and about 50% of the time was rated as uncertain. For cement augmentation, the scenarios without stenosis or neurological changes, stable fractures with less than 80% height loss and intact posterior wall, and higher VAS pain scores accounted for 88% probability of an appropriate rating. Otherwise, cement augmentation was uncertain 68% of the time. Surgery was rated as appropriate with agreement in 35%, and uncertain or appropriate with disagreement in 59% of scenarios. The most important variables determining final rating for surgery (in order) were stability, spinal stenosis, and prognosis.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria were generated based on the RAND methodology. Recommendations were made for medical treatment, ablation, radiation, cement augmentation, and surgery based on 432 practical clinical scenarios. This document provides comprehensive evidence-based recommendations for evaluation and treatment of metastatic neoplastic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Development and validation of a machine learning-based postoperative prognostic model for plasma cell neoplasia with spinal lesions as initial clinical manifestations: a single-center cohort study

BACKGROUND

Spinal multiple myeloma (MM) and solitary plasmacytoma of bone (SPB), both plasma cell neoplasms, greatly affect patients' quality of life due to spinal involvement. Accurate prediction of surgical outcomes is crucial for personalized patient care, but systematic treatment guidelines and predictive models are lacking.

OBJECTIVE

This study aimed to develop and validate a machine learning (ML)-based model to predict postoperative outcomes and identify prognostic factors for patients with spinal MM and SPB.

METHODS

A retrospective analysis was conducted on patients diagnosed with MM or SPB from 2011 to 2015, followed by prospective data collection from 2016 to 2017. Patient demographics, tumor characteristics, clinical treatments, and laboratory results were analyzed as input features. Four types of ML algorithms were employed for model development. The performance was assessed using discrimination and calibration measures, and the Shapley Additive exPlanations (SHAP) method was applied for model interpretation.

RESULTS

A total of 169 patients were included, with 119 for model training and 50 for validation. The Gaussian Naïve Bayes (GNB) model exhibited superior predictive accuracy and stability. Prospective validation on the 50 patients revealed an area under the curve (AUC) of 0.863, effectively distinguishing between 5-year survivors and non-survivors. Key prognostic factors identified included International Staging System (ISS) stage, Durie-Salmon (DS) stage, targeted therapy, and age.

CONCLUSIONS

The GNB model has the best performance and high reliability in predicting postoperative outcomes. Variables such as ISS stage and DS stage were significant in influencing patient prognosis. This study enhances the ability to identify patients at risk of poor outcomes, thereby aiding clinical decision-making.

Lesions of the spinal cord caused by multiple myeloma: A systematic review and meta-analysis regarding the neurosurgical aspects of patient management

BACKGROUND

Multiple Myeloma is a B-cell malignancy which can cause variety of lesions of the spine and spinal cord. The management of patients with spinal cord compression (SCC), and the efficacy and security of minimally invasive therapeutic approaches, are the main topics of discussion.

METHODS

To systematically review the scientific literature on neurosurgical aspects of MM spinal cord lesion management, a search was conducted among scientific papers in the databases ScienceDirect, Cochrane Library, and PubMed using keywords and Boolean operators. These comprise MM and lesions of the spine and spinal cord. Each database was searched from the earliest available article to January 2017.

RESULTS

According to the literature, low-dose radiotherapy, antimyeloma medications, and bisphosphonates comprise the mainstay management for symptomatic spinal lesions. The decision to operation is based on presence of myelopathy and degree of spinal cord compression.

CONCLUSIONS

As a result of the analysis, the following conclusions may be drawn: (1) surgery is a valuable option for MM patients with symptomatic spinal involvement who experience rapid neurological deterioration with SCC and/or mechanical instability and (2) it is important to ensure that the benefits of surgical treatment outweigh the risks, as patients with MM are susceptible to infections.

Role of vertebroplasty and balloon kyphoplasty in pathological fracture in myeloma: a narrative review

BACKGROUND

Up to 70% of multiple myeloma (MM) patients develop vertebral metastasis and subsequent pathological vertebral fractures (PVF). With contemporary systemic therapies, life expectancy of MM patients has improved drastically, and the need to manage pain and associated disability from PVF is increasingly a high priority. The aim of this review is to provide an updated comprehensive synthesis of evidence in the use of vertebral augmentation, including percutaneous vertebroplasty (PV) and balloon kyphoplasty (BKP), to treat MM-related PVF.

METHODS

A comprehensive multi-database search in accordance with PRISMA guidelines was performed up to 10 February 2021. Relevant English language articles were selected and critically reviewed.

FINDINGS

A total of 23 clinical studies have been included in the review. PV and BKP showed significant pain and functional improvements in terms of analgesia requirements, Cervical Spine Function Score, Eastern Cooperative Oncology Group scale, EQ-5D score, Karnofsky score, Neck Pain Disability Index, Oswestry Disability Index, Short form-36 (SF-36) questionnaire and VAS pain scale. Both procedures also reported promising radiographic outcomes in terms of vertebral height improvement, maintenance and restoration, as well as kyphotic deformity correction. Asymptomatic cement leakage was commonly reported. There was no significant difference between the two procedures.

CONCLUSION

PV and BKP are safe and effective procedure that offers pain relief, reduction in pain associated disability and reduction of fracture incidence. Its minimally invasive approach is associated with minimal morbidity risk, making it a viable option in frail patients.

LEVEL OF EVIDENCE IV

Narrative review.

Vertebroplasty or kyphoplasty as palliative treatment for cancer-related vertebral compression fractures: a systematic review

BACKGROUND CONTEXT

Percutaneous vertebroplasty (PVP) and kyphoplasty (KP) are minimally invasive treatment options for vertebral compression fractures (VCFs) due to malignancy.

PURPOSE

To perform a systematic review evaluating the effectiveness and safety of vertebral augmentation for malignant VCFs.

STUDY DESIGN

Systematic review.

STUDY SAMPLE

Studies on PVP or KP for VCFs in patients with malignant spinal lesions.

OUTCOME MEASURES

Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), Karnofsky Performance Score (KPS), and complications were extracted from eligible studies.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, studies published between January 1, 2000 and January 3, 2018 were identified by combining the results of a report by Health Quality Ontario with an updated literature search.

RESULTS

The review identified two randomized controlled trials, 16 prospective studies, 44 retrospective studies, and 25 case series for a patient sample size of 3,426. At the earliest follow-up, pain improved from 7.48 to 3.00 with PVP, and from 7.05 to 2.96 with KP. ODI improved from 74.68 to 17.73 with PVP, and from 66.02 to 34.73 with KP. KPS improved from 66.99 to 80.28. Cement leakage was seen in 37.9% and 13.6% of patients treated with PVP and KP, respectively. Symptomatic complications (N = 43) were rare.

CONCLUSIONS

This review showed clinically relevant improvements in pain, ODI, and KPS in patients with VCFs due to malignancy treated with either PVP or KP. Cement leakage is common, but rarely symptomatic. Percutaneous vertebroplasty and KP are safe and effective palliative procedures for painful VCFs in patients with malignant spinal lesions.

PKP/PVP combine chemotherapy in the treatment of multiple myeloma patients with vertebral pathological fractures: minimum 3-year follow-up of 108 cases

Background

Multiple myeloma (MM) is a blood system malignant tumor, which often leads to osteolytic bone destruction, and the vertebral column is the primary site of involvement. However, the efficacy and prognosis of percutaneous kyphoplasty/vertebroplasty (PKP/PVP) for simple vertebral pathological fractures in patients with multiple myeloma are not yet unified. The primary objective of this study was to investigate the efficacy and prognosis of PKP/PVP in the treatment of multiple myeloma patients with vertebral pathological fractures.

Methods

A total of 108 patients with MM from Beijing Chao-Yang Hospital from 2007 to 2013 were enrolled. Of these, 52 patients underwent PKP/PVP surgery and chemotherapy (surgery group) and 56 received only chemotherapy (chemotherapy group). The age, gender, International Staging System (ISS), fracture location, segment, visual analog scale (VAS), Oswestry Disability Index (ODI), comprehensive treatment satisfaction, stem cell transplantation, overall survival (OS), mortality rate, and the cause of death of patients were recorded; the mean follow-up time was 42.46 months.

Results

The average age of patients in surgery and chemotherapy groups was 60.8 years and 58.1 years, and the mean survival time was 41.98 months and 43.30 months, respectively. The VAS score at 1 month and last follow-up after treatment in surgery group were significantly lower than those in the chemotherapy group (P < 0.05); the ODI at 1 month after treatment in the surgery group was significantly lower than that in the chemotherapy group (P < 0.05); no significant difference was observed in the 3-year mortality rate between surgery and chemotherapy groups. The number of patients who developed activity disorder in the surgery group was significantly less than that in the chemotherapy group (P < 0.05). The OS of patients in ISS stage III was significantly less than that in ISS stages I and II (P < 0.05).

Conclusions

PKP/PVP surgery can greatly relieve the pain caused by fractures, reduce the risk of being completely bedridden and pulmonary infection, and improve the quality of life of patients; however, it did not affect mortality rate and overall survival time in patients.

Trial registration

As this was a retrospective study, it did not require ethical approval; all patients had signed informed consent when they received treatment, and all treatment options were voluntary.

Trends in vertebral augmentation for spinal fractures in myeloma patients: a 2002–2012 population-based study using a large national cancer registry

Purpose

To evaluate temporal trends and factors associated with vertebral augmentation use in myeloma patients with spinal fractures from 2002 to 2012.

Methods

This retrospective cohort study used the Surveillance, Epidemiology and End Results (SEER)-Medicare claims database for 2002 through 2012. We included patients age ≥66 years with myeloma and spinal fractures. First, we evaluated receipt of vertebral augmentation. Second, multivariate logistic regression was used to assess the impact of sociodemographic factors, treatment facility type, and underlying comorbidities on the odds of undergoing vertebral augmentation.

Results

Of 4725 myeloma patients with spinal fractures, 653 underwent vertebral augmentation. Procedures increased initially from <1.7% in 2002 to 21.0% (109/520) in 2007, 18.6% (81/435) in 2008, 21.4% (109/509) in 2009, and 17.5% (76/435) in 2011. Patients with a spinal fracture before myeloma diagnosis were twice as likely to undergo vertebral augmentation as patients with fracture after myeloma diagnosis (OR 2.06, 95% CI 1.55 to 2.75). Black patients were half as likely to undergo vertebral augmentation as white patients (OR 0.48, 95% CI 0.34 to 0.68). Patients with 3–5 comorbidities (OR 0.78, 95% CI 0.64 to 0.96) and ≥6 comorbidities (OR 0.69, 95% CI 0.54 to 0.87) were less likely than patients with 0–2 comorbidities to undergo vertebral augmentation.

Conclusions

Vertebral augmentation for myeloma patients with spinal fractures peaked between 2007 and 2009 and then declined. Providers may have adopted vertebral augmentation in myeloma patients since its introduction, and potentially modified practice patterns following the publication of trials of vertebral augmentation in patients with osteoporotic spinal fractures.

Consensus on Surgical Management of Myeloma Bone Disease

Myeloma bone disease (MBD), the skeletal lesions caused by multiple myeloma, is also known as skeletal related events and includes bone pain, osteoporosis, pathological fractures, osteolytic bone lesions, spinal instability, spinal cord and nerve root compression and extramedullary plasmacytoma. It is now generally accepted that patients with these complications usually require surgical management and that such treatment is safe and effective. The aims of surgical interventions are to alleviate pain, improve quality of life, treat potential or existing pathological fractures, decompress the spinal cord and nerve roots, and reestablish bone continuity. Thus far, there have not been uniform standards for surgical treatment of MBD. The Surgeon's Committee of the Chinese Myeloma Working Group has therefore achieved a consensus with the aim of providing guidance for clinicians and benefitting patients with MBD. This consensus focuses on the treatment of MBD, including its clinical definition and characteristics, diagnosis and surgical management. This expert consensus document was compiled after discussion and revision by experts from several relevant institutions in China. However, it is only an interim guide that cannot be enforced legally. It will be updated with development of new techniques of treatment.

Subsequent Vertebral Fractures Post Cement Augmentation of the Thoracolumbar Spine: Does it Correlate With Level-specific Bone Mineral Density Scores?

STUDY DESIGN

A case-control study.

OBJECTIVE

In this study, we investigated the correlation between level-specific preoperative bone mineral density and subsequent vertebral fractures. We also identified factors associated with subsequent vertebral fractures.

SUMMARY OF BACKGROUND DATA

Complications of cement augmentation of the spine include subsequent vertebral fractures, leading to unnecessary morbidity and more treatment. Ability to predict at-risk vertebra will help guide management.

METHODS

We studied all patients with osteoporotic compression fractures who underwent cement augmentation in a single institution from November 2001 to December 2010 by a single surgeon. Association between level-specific bone mineral density T-scores and subsequent fractures was assessed. Multivariable analysis was performed to identify significant factors associated with subsequent vertebral fractures.

RESULTS

93 patients followed up for a mean duration of 25.1 months (12-96) had a mean age of 76.8 years (47-99). Vertebroplasty was performed in 58 patients (62.4%) on 68 levels and kyphoplasty in 35 patients (37.6%) on 44 levels. Refracture was seen in 16 patients (17.2%). The time to subsequent fracture post cement augmentation was 20.5 months (2-90). For refracture cases, 43.8% (7/16) fractured in the adjacent vertebrae. Subsequently fractured vertebra had a mean T-score of -2.860 (95% confidence interval -3.268 to -2.452) and nonfractured vertebra had a mean T-score of -2.180 (95% confidence interval -2.373 to -1.986). A T-score of -2.2 or lower is predictive of refracture at that vertebra (P = 0.047). Odds ratio increases with decreasing T-scores from -2.2 or lower to -2.6 or lower. A T-score of -2.6 or lower gives no additional predictive advantage. After multivariable analysis, age (P = 0.049) and loss of preoperative anterior vertebral height (P = 0.017) are associated with refracture.

CONCLUSION

Level-specific T-scores are predictive of subsequent fractures and the odds ratio increases with lower T-scores from -2.2 or less to -2.6 or less. They have a low positive predictive value, but a high negative predictive value for subsequent fractures. Other significant associations with subsequent refractures include age and anterior vertebral height.

LEVEL OF EVIDENCE

4.

Postoperative cement augmentation after 360-degree fixation for highly unstable vertebral fractures in patients with multiple myeloma: a technical note on delayed trans-instrumentation vertebroplasty

BACKGROUND

Although surgical fixation is usually not part of the first-line treatment of spinal lesions in patients with multiple myeloma, there are some unique clinical situations (such as the presence of acute onset of neurological deficits) in which spinal decompression and instrumentation may be required. In such scenario, because of the presence of poor bone quality, the strength of the spinal construct is of paramount importance. Although several studies have demonstrated the benefits of cement augmentation in increasing the pullout strength of pedicle screw fixation, the injection of cement during placement of pedicle screws may hamper the possibility of additional circumferential screw fixation. In addition, cement injection into vertebral bodies full of tumor and in the presence of adjacent epidural disease may incur in higher risks of tumor extravasation and worsening of neurological deficits than cement injection after initiation of adjuvant therapies.

CASE DESCRIPTION

The advantages of delayed trans-instrumentation vertebroplasty after 360-degree fixation are discussed in this technical note with an illustrative case of a patient with multiple myeloma presenting with cauda equina syndrome after a T12 compression fracture.

CONCLUSIONS

In spite of the associated challenges of such an interventional procedure due to the presence of extensive hardware, carrying out delayed trans-instrumentation vertebroplasty after 360-degree circumferential fixations is not only feasible, but in our opinion, may constitute the best strategy to optimize the strength of spinal instrumentation in challenging scenarios involving poor bone quality, such as in patients with multiple myeloma.

Discharge disposition following vertebroplasty

BACKGROUND AND PURPOSE

A variety of factors, such as pain level at rest and with activity, have been used to assess outcome of the VP procedure. However, few studies have assessed discharge disposition as a reflection of VP efficacy in the inpatient population. The purpose of this study was to compare patient disposition status before and after VP and determine what relationship exists between the treatment and patient discharge status.

MATERIALS AND METHODS

We performed a retrospective review of inpatients who underwent consultation for consideration of spinal augmentation for treatment of painful vertebral compression fractures. We gathered data concerning patients' demographics, living arrangements before hospitalization, discharge disposition, quantitative and qualitative pain levels, and length of hospital stay before and following VP.

RESULTS

Ninety inpatients underwent VP, 73 (81%) of whom lived independently at home before hospitalization. Of these 73 patients, 31 (42%) returned home after discharge, 9 (12%) returned home with home health care assistance, and 32 (44%) were sent to skilled nursing facilities. Six (7%) of the 90 patients resided in assisted-living centers before hospitalization; all of these patients were discharged to assisted-living or skilled nursing facilities. Eight (9%) of the 90 patients resided at skilled nursing centers before hospitalization, and all returned to nursing centers after their hospital stay. Discharge disposition was not significantly associated with preoperative pain levels at rest or with activity (P = .76 and P = .23, respectively) or with postoperative pain levels at rest or with activity (P = .08 and P = .25, respectively).

CONCLUSIONS

This study demonstrates that patients undergoing VP as inpatients are often discharged to rehabilitation centers rather than home, irrespective of their status before hospitalization or their pre- and postoperative pain levels.