Effect of Systemic Therapies on Outcomes following Vertebroplasty among Patients with Multiple Myeloma

BACKGROUND AND PURPOSE:The role of vertebroplasty in patients with myeloma remains relatively undefined. Accordingly, we sought to better define the efficacy of vertebroplasty for myeloma-associated fractures and determine the effect of procedure timing relative to the initiation of systemic therapy on outcomes and complication rates.MATERIALS AND METHODS:Clinical, laboratory, and medication data were retrieved for 172 patients with multiple myeloma treated with vertebroplasty since October 2000. Quantitative outcome data (Roland-Morris Disability Questionnaire [scale, 0–24] and the Numeric Rating Scale [0–10] for pain at rest and with activity) were collected immediately pre- and postoperatively and at 1 week, 1 month, 6 months, and 1 year following vertebroplasty. Patients with ≥50% improvement on the Numeric Rating Scale and ≥40% improvement on the Roland-Morris Disability Questionnaire were classified as “responders.” Peri- and postoperative complications were also collected.RESULTS:Significant median improvement in the Roland-Morris Disability and rest and activity Numeric Rating Scale scores (15, 2, and 6 points, respectively; P < .0001) persisted at 1 year without significant change from the immediate postoperative scores (P > .36). Patients on systemic therapy at the time of vertebroplasty were more likely to achieve “responder status,” compared with patients not on systemic therapy, for the Numeric Rating Scale pain at rest score (P < .01) and the Roland-Morris Disability Questionnaire score (P < .003), with no difference in complication rates (χ² = 0.17, P = .68).CONCLUSIONS:Vertebroplasty is an effective therapy for patients with myeloma with symptomatic compression fractures. Favorable outcomes are more likely to be achieved when spinal augmentation is performed after systemic therapy is initiated. Complication rates were not affected by the timing of systemic therapy.

For the past 20 years, vertebroplasty has been shown to be an effective treatment for symptomatic vertebral compression fractures refractory to medical therapy.^1,2 Although recent evidence suggests that the pain reduction derived from this procedure may not be attributable to the injection of the cement itself, the data are clear that vertebroplasty recipients experience durable improvement in mobility and reduced narcotic use that persist for months to years following therapy.³ Although patients with osteoporosis comprise most vertebroplasty recipients in the United States, traumatic and pathologic fractures have also been treated with percutaneous spinal augmentation.^4–6 Among pathologic fracture etiologies, multiple myeloma is one of the more common indications for intervention. Patients with myeloma are particularly prone to pathologic vertebral compression fractures due to systemic osteoporosis from cytokine-mediated imbalance of osteoclast and osteoblast function and systemic corticosteroid therapy.⁶Although a large body of evidence exists demonstrating the efficacy of vertebroplasty among patients with benign osteoporotic vertebral compression fractures, the data in support of its use in the treatment of pathologic fractures among patients with multiple myeloma remain limited. In part, data from patients with myeloma are limited due to their reduced survival time, clinical uncertainty with respect to improvement in pain in the setting of diffuse disease, uncertainty as to when to treat, and a higher threshold of treatment criteria for patients with diffuse disease. In contradistinction to patients with benign compression fractures, patients with myeloma are often on multidrug systemic therapy and may have hematologic derangements related to their disease and/or treatment. These factors may confound outcomes and potentially render patients with myeloma more predisposed to adverse events.The purpose of this study was to better define the efficacy of vertebroplasty for myeloma-associated fractures and determine the effect of procedure timing relative to the initiation of systemic chemotherapy and the extent of disease on outcomes and complication rates.