HISTORY
This 65-year-old female patient presents with acute symptoms of right-sided radiculopathy, paresthesia and pain in the right upper extremity. There has been no trauma.
DIAGNOSIS
Observe the gross osteoporosis about the entire cervical spine. There has been pathological collapse of the C5 vertebral body, which is uniform in configuration. This is very characteristic of a malignant pathological fracture. This patient’s radiculopathy occurred as a result of posterior compression on the spinal cord resulting from the pathological collapse. The compression created an extradural defect on the spinal cord.
General Considerations
Multiple myeloma occurs as a result of a malignant proliferation of plasma cells, which infiltrate the bone marrow. The first patient known to have multiple myeloma was seen in 1845, after severe recurrences of pain during a 17-month period. His urine contained unusual “animal matter” that became soluble when boiled and formed again when cooled. Although William MacIntyre recognized the effect of heat on the urine and outlined the clinical findings, it was the young physician and chemist Henry Bence Jones who described the protein in detail. In 1873, von Rustizky named and outlined in detail the clinicopathologic features of the this disease. Multiple myeloma is occasionally referred to as Kahler’s disease, after the clinician from Prague who lectured extensively on myeloma in the late nineteenth century. In more recent times, the diagnosis of myeloma was facilitated by Longsworth, et al., in 1939, with the development of electrophoretic techniques and with immunoelectrophoresis as described by Grabar and Williams.
Incidence
Multiple myeloma is the most common primary malignant tumor of bone and accounts for 27 percent of biopsied bone tumors. Together, myeloma and osteosarcoma account for almost half (46 percent) of the primary malignant tumors of bone. Multiple myeloma represents about one percent of all types of malignant disease and slightly less than ten percent of hematologic malignancies. In the last two decades, the death rate from multiple myeloma has increased; however, it is likely that these increases are related to earlier and more improved diagnosis rather than representing an actual rise in incidence.
Clinical Features
Age and Sex Distribution: Typically 75 percent of myeloma patients are between fifty and seventy years of age, with an average age of sixty. It is rarely seen before the age of forty, but a few cases have been reported before the age of thirty. There is a male to female ratio of 2:1.
Signs and Symptoms: The clinical picture of the disease comprises four types of abnormalities: anemia owing to replacement or alteration of the hematopoietic tissues by proliferating plasma cells, deossification of bones that house red marrow production of abnormal serum and urinary proteins, and renal disease. Pain is the cardinal initial symptom, often suggesting arthritis or neuralgia.
Initially, the bone pain is intermittent; in later stages, it becomes continuous. It is worse during the day and aggravated by exercise and weight bearing. The pain is often better at night with bed rest. Low back pain in myeloma patients is frequently misdiagnosed as disc or sciatic problems initially. A rapid onset of severe pain after slight strain or mild trauma usually indicates the development of a pathologic fracture. In the late stages of the disease, pathologic fractures occur in 20 percent of patients. Paraplegia may occur with vertebral collapse and is more common with a solitary presentation (plasmacytoma). As the disease progresses, the pain becomes more severe and prolonged, often requiring narcotics for relief.
SOLITARY PLASMACYTOMA
General Considerations
Solitary plasmacytoma represents a localized form of plasma cell proliferation. It is much less common than multiple myeloma. Approximately 50 percent of patients present before age fifty. Most commonly, patients complain of localized pain. Laboratory findings are occasionally normal, or the abnormal serum electrophoresis may disappear after tumor excision. The mandible, ilium, vertebrae, ribs and proximal femur and scapula are the favored sites. Pathologic fracture is common. Isolated cases have been reported in extramedullary sites affecting the soft tissues of the upper respiratory tract. Rarely, solitary plasmacytoma can present as an ivory vertebra. The typical roentgen appearance is a geographic radiolucent lesion, often highly expansile, with a soap bubble internal architecture. The radiographic differential diagnosis includes pseudo-tumor of hemophilia, hydatid disease of bone, fibrous dysplasia, giant cell tumor, brown tumor of hyperparathyroidism, and blow-out metastases from renal or thyroid origin.
Often, these lesions initially appear benign; however, 70 percent of patients who have what seems to be a solitary focus develop diffuse multiple myeloma and die within five years. Progression to multiple myeloma has been documented in cases up to twenty-three years after the initial presentation of solitary plasmacytoma, emphasizing the importance of long-term follow-up with these patients. The balance of the lesions remain localized and are treated quite successfully with local irradiation and/or surgical excision.
Dr. Terry R. Yochum is a second generation chiropractor and a Cum Laude Graduate of NationalCollege of Chiropractic, where he subsequently completed his radiology residency. He is currently Director of the Rocky Mountain Chiropractic Radiological Center in Denver, Colorado, and Adjunct Professor of Radiology at the Southern California University of Health Sciences, as well as an instructor of skeletal radiology at the University of Colorado School of Medicine, Denver, CO. Dr. Yochum can be reached at 303-940-9400 or by e-mail at [email protected].
Dr. Chad J. Maola is a 1990 Magna Cum Laude Graduate of National College of Chiropractic. Dr. Maola is a Chiropractic Orthopedist and is available for post-graduate seminars. He may be reached at 303-690-8503 or e-mail [email protected].
References
1. Yochum TR, Rowe LJ: Essentials of Skeletal Radiology, 3rd ed., Lippincott, Williams & Wilkins, Baltimore, Maryland, 2005.
2. Deutsch A, Resnick D: Eccentric cortical metastases to the skeleton from bronchogenic carcinoma, Radiology 137:49, 1980.
3. Yuh WTC, Zachar CK, Barloon TJ, et al.: Vertebral compression fractures: Distinction between benign and malignant causes with MRI Imaging. Radiology 172:215, 1989.
4. Shih TT, Huang KM, Li YW: Solitary vertebral collapse: Distinction between benign and malignant causes using MR patterns. J Magnetic Reson Imaging 9(5):635, 1999.