Reduced Pain and Improved Mobility Gained When Reduced Pain and Improved Mobility Gained When Part of Treatment Plan for Vertebral Compression Part of Treatment Plan for Vertebral Compression

Fractures in Those With Fractures in Those With Multiple MyelomaMultiple Myeloma

Eren Erdem, MDInterventional Neuroradiologist

Division Director and Associate Professor

University of Arkansas for Medical SciencesUniversity of Arkansas for Medical Sciences

Vertebroplasty: Integral to Treating Back Vertebroplasty: Integral to Treating Back Pain in Blood Marrow Cancer PatientsPain in Blood Marrow Cancer Patients

The minimally invasive, image-guided treatment of vertebroplasty is an integral component to the complicated treatment of multiple myeloma, an incurable (yet treatable) cancer of the bone marrow that causes destructive lesions in bones and makes them more susceptible to fracture.

Vertebral compression fractures are very common in patients with multiple myeloma

(up to 70 %) and cause severe pain and debilitation.

Patients can experience compression of abdominal contents, decrease in lung capacity, depression, anorexia and reduced ability to perform normal daily functions

By reducing pain and improving mobility, vertebroplasty helps patients become better equipped to continue with their rigorous treatment for multiple myeloma

• Founded 1989, Bart Barlogie, MD, PhDFounded 1989, Bart Barlogie, MD, PhD

EpidemiologyEpidemiology

• 10% hematologic malignancies, 1% all10% hematologic malignancies, 1% all

• Incidence 3-4/10Incidence 3-4/1055, 20,000/year US, 20,000/year US

• 100,000 US patients in treatment100,000 US patients in treatment

• 3:2 Male to female ratio3:2 Male to female ratio

• African-Americans increased riskAfrican-Americans increased risk

Multiple MyelomaMultiple Myeloma

Uncontrolled overgrowth of plasma cellsUncontrolled overgrowth of plasma cells

• Bone marrow failureBone marrow failure AnemiaAnemia

Immune dysfunctionImmune dysfunction

• Monoclonal Protein SecretionMonoclonal Protein Secretion Renal FailureRenal Failure

• Increased osteoclast, decreased osteoblast activityIncreased osteoclast, decreased osteoblast activity Bone destructionBone destruction

Osteoclast & Osteblast Osteoclast & Osteblast “Un-coupling”“Un-coupling”

Bone DestructionBone Destruction

SEM courtesy of Dr. Arnett, UCL

Secondary osteoporosisSecondary osteoporosis

Study ObjectiveStudy Objective

• Distribution and Extent Vertebral FracturesDistribution and Extent Vertebral Fractures

• Efficacy of Vertebral AugmentationEfficacy of Vertebral Augmentation– PainPain– Analgesic UsageAnalgesic Usage– DisabilityDisability

Material & MethodsMaterial & Methods

• 792 consecutive MM patients792 consecutive MM patients

• January 2001 through May 2007January 2001 through May 2007

• Prospective, IRB-approved studyProspective, IRB-approved study

ResultsResults

n=792

n=440 mean age 61.6 yrs, SD 10.9 p<0.001n=352 65.6 yrs, SD 13.0

ResultsResults

ResultsResults

ResultsResults

ResultsResults

ResultsResults• Pain AssessmentPain Assessment

p < 0.001

n=520

ResultsResults

ResultsResults

Vertebroplasty ProcedureVertebroplasty Procedure

• Under local and intravenous medication

• No surgical incision

• Needles are placed into the vertebral bone precisely, under advanced live x-ray

• The cement is then injected very carefully to stabilize the fracture and alleviate pain

• Most procedures are done outpatient and rarely requires limited time in the hospital

• There’s no incision, so there’s less pain and less recovery time, only a bandaid

• Less expensive than surgery

Multiple Myeloma can be very debilitatingMultiple Myeloma can be very debilitating

one month laterone month later

Pre/Post treatment –Jan 2005Pre/Post treatment –Jan 2005

Improved kyphosis

When there is no pressure on the spinal When there is no pressure on the spinal cord even the worst fractures can be cord even the worst fractures can be

treated with vertebroplasty treated with vertebroplasty

Retropulsion Retropulsion

Why not open surgery?Why not open surgery?

• Open surgery is the last resort for multiple myeloma and other cancer patients with metastasis to the vertebra

• Usually, the bones don’t have enough structure to anchor instruments such as screws and plates

• Also, being sick with cancer, these are very aggressive surgeries to handle for the patients

Failed back sugeryFailed back sugery

When there is aggressive tumor, When there is aggressive tumor, interventional radiologists would ablate interventional radiologists would ablate

the tumor at the time of vertebroplasty, to the tumor at the time of vertebroplasty, to achieve local disease control as well achieve local disease control as well

T 11 expansile lesionT 11 expansile lesion

RFA and Cement injectionRFA and Cement injection

5 days post RFA5 days post RFA

When the patient has many fractures and When the patient has many fractures and decompensated, aggressive but safe long decompensated, aggressive but safe long

procedures can be performedprocedures can be performed

14 levels treated

only two procedures

ConclusionConclusion

Although there is multiple large series of the procedure’s success in osteoporotic patients, this is the first large series on a cancer population of multiple myeloma

With increasing experience, interventional radiologists can effectively treat the most complex and difficult cases of compression fractures throughout the spinal column with vertebroplasty