Dr. David Roodman of the University of Pittsburgh presented these findings at the International Myeloma Workshop (IMW) on May 6 in Paris.

Most multiple myeloma patients develop bone disease, which can cause bone fractures that are extremely painful and debilitating. The current gold standard for treating myeloma bone disease is bisphosphonates, a class of drugs that slow the breakdown of bone, thereby reducing the number of fractures.

Patients diagnosed with either smoldering myeloma or monoclonal gammopathy of undetermined significance, which are both asymptomatic diseases that can progress to myeloma, may also experience bone complications. According to Dr. Roodman, it is unclear whether these patients should be treated with bisphosphonates.  For now, the guidelines recommend that patients with these conditions should only use bisphosphonates if diagnosed with osteoporosis from a DEXA scan, which measures bone density and strength. However, all patients with high-risk smoldering myeloma and bone loss should consider bisphosphonate treatment.

Solitary plasmacytoma is another precursor disease in which the patient has a single mass of myeloma cells that often result in a bone lesion.  The guidelines do not recommend bisphosphonate treatment for this type of patient.

For myeloma patients with multiple lesions, the guidelines recommend treatment with a bisphosphonate.  For myeloma patients without evidence of bone disease, it is unclear whether they should be treated with bisphosphonates. Some research has shown bisphosphonate use may have a clinical benefit even in patients without bone disease.

Some bisphosphonates are administered orally, while others are administered through intravenous injections. The guidelines recommended that patients use intravenous bisphosphonates, such as Zometa (zoledronic acid), due to results from a recent clinical trial that suggested this bisphosphonate may extend survival. In addition, they recommended that physicians administer standard doses of bisphosphonates every three to four weeks.

It is still unclear how long bisphosphonates should be used.  There is currently no randomized data on bisphosphonate use for more than two years. As a result, physicians should assess a patient’s risk and benefit of using bisphosphonate treatment after two years.

For instance, researchers have speculated that long-term use of bisphosphonates increases one’s risk of developing osteonecrosis of the jaw, a rare but serious side effect of bisphosphonate use in which there is a loss of blood supply to the jaw, causing jawbone tissue to die. To prevent osteonecrosis of the jaw, patients treated with bisphosphonates should maintain good dental hygiene and should stop bisphosphonate treatment for 90 days before and after invasive dental procedures.

Rare fractures of the upper leg and in the feet have also been reported after long-term use of bisphosphonates.

The guidelines also recommend that myeloma patients make sure to get enough vitamin D and calcium, nutrients essential for strong and healthy bones.  This is a concern because sixty percent of myeloma patients are vitamin D and calcium deficient. The guidelines say that patients may use vitamin D and calcium supplements with bisphosphonate treatment, but calcium supplementation should be used cautiously for patients with kidney problems.

Minimally invasive surgery can also be used to reduce pain associated with a spinal compression fracture and to improve a patient’s functional ability. In particular, the guidelines recommended kyphoplasty, a procedure in which a physician inserts and inflates a small balloon into the fractured vertebra, creating a space that is then filled with an acrylic cement to stabilize the spinal cord. However, there is conflicting evidence as to the benefits of vertebroplasty, a procedure in which the cement is injected directly into the fractured vertebra.

Radiation therapy may also be used for pain reduction and localized improvements in function. However, it should only be used in urgent cases, depending on a patient’s prior treatment history and response, due to its impact on bone marrow function.

For more information, please see the full guidelines (pdf), which are available on the IMW website.

At least 70 percent of multiple myeloma patients suffer from bone disease, which is characterized by bone pain, fractures, and elevated calcium levels.  Patients frequently experience compression fractures in the spine, which may cause back pain, partial paralysis of limbs, decreased sensation, and poor urinary control.

Researchers are currently evaluating the success of treating spinal compression fractures with a procedure called vertebroplasty. During this procedure, doctors inject acrylic cement into the patient’s collapsed vertebrae. Although vertebroplasty has been shown to improve patient back pain and general quality of life, researchers have yet to determine the procedure’s long-term effects in multiple myeloma patients.

In their study, a group of Italian researchers completed a prospective analysis of 625 vertebroplasty procedures performed on 106 myeloma patients from 2002 to 2009. All patients had at least 12 months of follow-up. The median follow-up time was 28 months.

The researchers found that at follow-up, patient pain had decreased significantly compared to prior to surgery. On a scale of 1 to 10, patients ranked their pain level at an average value of 9 prior to surgery. After surgery, the pain level decreased to an average value of 1.

The level of disability also decreased significantly after surgery. On a scale of 0 percent (no disability) to 100 percent (bed bound), the median pretreatment disability level was 82 percent. After surgery, the median disability level decreased to 7 percent, with 26 percent of patients reporting no disability.

All of the patients were taking pain-relieving medications prior to surgery; however, following the procedure, 51 percent of patients no longer needed these medications and the majority of other patients were able to lower the medication dose required for pain management.

Before the procedure, 76 percent of patients wore an orthopedic brace to assist with back pain. After treatment, only 14 percent still required the brace.

Cement leakage, the most common complication of vertebroplasty, occurred in 23 percent of cases.

During follow-up, 15 percent of patients reported new back pain, which was later confirmed with x-rays and MRI to be new spinal compression fractures due to disease progression. These patients all received a second vertebroplasty, which successfully treated the new spinal fractures.

For more information about this study, please refer to the study in the journal Cardiovascular and Interventional Radiology (abstract).

Weakening of the vertebrae, the bones that make up the spine, can result in vertebral compression fractures. Though the most common cause of vertebral compression fractures is osteoporosis, they may also be caused by multiple myeloma tumors.

Patients with vertebral compression fractures often suffer from debilitating pain and may experience changes in their height. Non-surgical treatments for vertebral fractures include radiation, pain medication, short periods of bed rest, calcium and vitamin D supplementation, as well as the use of external back braces. Patients whose compression fractures do not respond to medical treatment can undergo surgical procedures to treat their fractures.

ArthroCare’s Contour device uses a movable, curved needle to displace soft bone, creating a space into which bone cement can be delivered to stabilize the fracture. It is used with vertebroplasty or kyphoplasty procedures, in which physicians use image guidance to inject bone cement through a hollow needle into the fractured bone.

The Contour device would most likely be used as an alternative to balloon kyphoplasty, in which an inflatable balloon is inserted through a needle into the fractured bone, creating a space for bone cement to be delivered after removal of the balloon.

Leakage of the cement out of the vertebrae is a potential complication of these procedures. In a new procedure, known as vesselplasty, a small bag is placed inside the vertebra before the addition of the bone cement to reduce the risk of cement leakage.

For more information, please see the ArthroCare press release.

Myeloma cells accelerate processes that degrade bone, resulting in bone lesions and fractures. Spinal fractures, in particular, are a common complication associated with multiple myeloma and can leave patients unable to walk. Treatment options include radiation therapy, medication, and a minimally invasive procedure called vertebroplasty (for further description, see related Beacon article).

In the study, researchers looked back at the recovery data of 11 patients, all of whom had undergone at least one vertebroplasty procedure at the Instituto Clinico Humanitas, a medical institution in Italy, over a two-year period. Three patients received an additional vertebroplasty later on, bringing the total number of procedures performed to 14. Doctors examined the procedure’s effectiveness and safety.

Despite the aid of medication and bed rest, all 11 patients still experienced pain and on a scale of 1 to 10, ranked their pain at an average value of 7 prior to surgery. After surgery, patient pain decreased to an average value of 2.

After 11 of the 14 procedures (79 percent), patients experienced pain relief almost immediately. The other three procedures (21 percent) required 24 to 36 hours for pain relief to occur. In all instances, patients were discharged two days after the treatment.

Of the eight patients who initially needed orthopedic devices to walk, five patients (63 percent) no longer required the aids two weeks after treatment. Two of the three patients who needed walking aids after surgery had initially been wheelchair-bound.

Pain relief remained consistent over follow-up periods ranging from 1 day to 25 months. However, three patients developed fractures at a new site in the spine and required a second vertebroplasty. In three procedures (21 percent), the bone cement leaked into nearby spaces in the spinal column, but the leaks were noted and repaired during surgery.

Leakage is the most common complication of vertebroplasty and can have serious implications if the cement travels into the spinal canal, home to the spinal cord. However, the risk of such a complication ranges from one to three percent.

Because patients experienced rapid and sustained pain relief and many no longer needed walking devices or medication, researchers described the study results as “excellent.” They concluded that vertebroplasty is an effective procedure in treating spinal fractures because it is relatively non-invasive, relieves pain rapidly, and has a low rate of complication. They also speculated that the surgery may be used to prevent vertebrae fractures in the future.

For more information, please see the journal Neurological Sciences (abstract).

Spinal fractures, also known as collapsed vertebrae or vertebral compression fractures, can develop in multiple myeloma patients who suffer from bone weakening.

Vesselplasty is a minimally invasive, image-guided surgical procedure that has emerged as an alternative to the conventional treatments of vertebroplasty and kyphoplasty.  A major advantage of vesselplasty is that it reduces leakage of cement out of the vertebral body, which is known to occur in both conventional treatments.  Leakage can trigger additional fractures in adjacent vertebral bodies.

In this study, 29 patients underwent vesselplasty treatment, seven of which had multiple fractures.  Of the 37 procedures performed, spinal fractures were caused by osteoporosis in 27 cases (73 percent), high-impact trauma in five (13.5 percent), multiple myeloma in three (8 percent), and metastatic fracture in two (5.4 percent).

Patients were scored before and after treatment on pain, mobility, and the need for painkillers.  Pain decreased from 8.72 to 3.38 after treatment, mobility impairment dropped from 2.31 to 0.59, and use of painkillers fell from 3.07 to 1.86.  All values were statistically significant, and no clinical complications arose.

The results of this study suggest that vesselplasty offers considerable improvements in pain, mobility, and use of painkillers in patients with spinal fractures.  The authors assert that the procedure is a safe and effective alternative to conventional spinal fracture treatments.

For more information, please see the study in the American Journal of Roentgenology (abstract).

The most common type of lesions that develop in myeloma patients are in the spinal column. Patients may mistake pain from the lesion, often in the lower back and ribs, to be general back pain. One possible cause for the pain is vertebral compression fractures, also known as spinal fractures. This happens because the bone in the spine is too weak to withstand pressure. Multiple fractures in the spine can cause a hunchback condition from shortening of the spine.

While over-the-counter and prescription medication could reduce pain, radiation therapy, vertebroplasty, and kyphoplasty are alternative treatments to consider.

About 70 percent of myeloma patients with bone lesions receive radiation therapy to relieve pain. Patients receive fairly low doses of radiation to destroy myeloma cells and relief is felt a few days after treatment. Radiation therapy can be used alone or with other therapies to treat bone disease. Higher doses are not given because they could compromise future myeloma treatments. Too much radiation therapy may have an adverse effect on a patient’s bone marrow, which is important for maintaining the immune system.

Vertebroplasty is a minimally invasive procedure in which bone cement is injected into the fracture to stabilize the spinal column. The procedure is done under local or general anesthesia. Patients must remain in bed for one hour after the procedure to let the cement harden, and an overnight stay is required.

Another treatment option is kyphoplasty. This is a technique similar to vertebroplasty that uses orthopedic balloons to expand the fracture before bone cement is injected into the cavity. Local or general anesthesia is used, and the procedure takes less than one hour per fracture. Kyphoplasty is minimally invasive and uses only two small one-centimeter incisions. Patients recover overnight and can return to daily activities by the next day. Pain is usually decreased, and the treatment is compatible with other myeloma treatments.

A common complication with both vertebroplasty and kyphoplasty is cement leakage to areas outside of the fracture. Balloon kyphoplasty has a low risk of heart attacks, stroke, and clots (blood, fat, or cement) that migrate to the lungs.

Patients who have unstable spinal fractures or a history of blood clots are not recommended to have kyphoplasty done. Myeloma patients considering any of these procedures are advised to consult a doctor to find out if they qualify as candidates.

For more information on myeloma bone disease and these treatments, see the full article in the American Society of Hematology’s 2008 Education Program Book, Hematology. Also see other Beacon articles related to myeloma bone disease: skeletal imaging, bisphosphonate treatment, and novel therapies. Information on vertebral compression fractures can be found on the International Myeloma Foundation Web site.