Introduction: Nearly 70% of patients with multiple myeloma (MM) experience vertebral fracture. As a consequence, these patients suffer significantly poorer quality of life. Despite this, no studies have investigated the rate of fracture progression over clinical follow-up to better understand the natural progression of MM-associated vertebral fractures.
Methods: A consecutive retrospective chart review of all patients with MM at a single tertiary-care institution was conducted. Baseline demographic, comorbidity, and fracture data were collected at presentation with vertebral fracture. Radiologic data were collected from midline-sagittal T1-weighted MRI. At baseline and each follow-up, anterior, middle, and posterior vertebral body height losses were recorded.
Results: Among 33 patients, 67 fractures were observed and followed. 64% of patients were female, with a mean age of 66. At baseline, mean anterior, middle, and posterior vertebral body height losses were 30%, 36%, and 15%, respectively. 43% of fractures were severe (Genant grade 3), and 33% of fractures were wedge morphology. At last follow-up (LFU), mean anterior, middle, and posterior height losses increased to 47% (p<0.001), 49% (p<0.001), and 28% (p<0.001), respectively, with more Genant grade 3 (75%, p<0.001) and wedge fractures (54%, p=0.03). On average, patients lost an additional 0.83% vertebral body height per month over follow-up, with the majority of height loss occurring within the first 24 months following presentation. Thoracic fractures were more severe than lumbar fractures at baseline (41% vs. 33% height loss, p=0.09) and LFU (58% vs. 46%, p=0.02). At LFU, thoracic fractures progressed towards wedge morphology (68%) to a greater degree than lumbar fractures (23%, p<0.001).
Conclusions: This study is the first to characterize the progression of MM-associated vertebral fractures over radiologic follow-up. We observed a mean vertebral body height loss of 0.83% per month. Over time, more fractured vertebrae exhibited wedge morphology, and thoracic fractures progressed to a greater degree than lumbar fractures.
Patient Care: The majority of patients diagnosed with multiple myeloma will suffer at least one vertebral fracture in their disease course. These fractures significantly diminish quality of life in a disease with a 30% 10-year overall survival. As such, more aggressive surveillance and treatment of these fractures may yield improved quality of life and protect against neurologic deterioration. In order to accomplish this, and understanding of the natural history of these fractures is required. In the present study, we observed significant and rapid fracture progression despite a high utilization of bisphosphonates. Fractures tended to progress toward severe wedge fractures within 24 months of fracture diagnosis. These patients can expect to lose nearly 1% in vertebral body height monthly, highlighting the necessity for early referral to spine specialists and evidence-based guidelines for spine surveillance and treatment in the myeloma population.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the importance of the progression of vertebral fractures in multiple myeloma in determining evidence-based guidelines for spine surveillance and treatment in the myeloma population.
2) Discuss, in small groups, strategies to identify patients at risk for rapid fracture progression, and when to intervene with vertebral augmentation and stabilization.
3) Identify an effective treatment of vertebral fractures in patients with multiple myeloma, including the use of evidence-based guidelines for spine surveillance as an algorithm for determining time for intervention.
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