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Spinal Cord Compression As a Consequence of Spinal Plasmacytoma in a Patient with Multiple Myeloma: a Case Report

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Spinal Cord Compression As a Consequence of Spinal Plasmacytoma in a Patient with Multiple Myeloma: a Case Report Case Report Spinal Cord Compression as a Consequence of Spinal Plasmacytoma in a Patient with Multiple Myeloma: A Case Report Rishi Jayesh Trivedi Faculty of Medical Sciences, University of Bristol, Bristol BS8 1TH, UK; [email protected]; Tel.: +44-7715-3286-79 Received: 4 December 2020; Accepted: 23 February 2021; Published: 25 February 2021 Abstract: Multiple myeloma (MM) is a B cell malignancy resulting in osteolytic lesions. Pathological fracture of the vertebral body resulting in spinal cord compression is a common complication and accounts for approximately 5% of patients with MM. To date, there are no definitive guidelines for the treatment of spinal cord compression as a consequence of MM. Radiotherapy has frequently been the preferred form of treatment. Some surgeons, however, feel that spinal lesions in multiple myeloma should be treated in the same manner as spinal metastases from solid organs. I report the management of a 46-year-old gentleman with multiple myeloma that had resulted in neural compression in the lumbar and thoracic areas. Initial emergent treatment in this patient consisted of spinal decompression and stabilisation. Keywords: multiple myeloma (MM); metastatic spinal cord compression; spinal decompression; spinal stabilisation 1. Introduction The spine is the most common site for skeletal metastasis, with lesions of the axial skeleton representing roughly 39% of all bony metastases. Breast, prostate, and lung cancers classically represent the most common primary tumours with propensity to metastasize to the bony spine due to its rich vascular supply and the valveless nature of the epidural venous plexus described by Batson [1,2]. The incidence of metastatic spinal cord compression (MSCC) is up to 80 cases per million people each year [3]. This equates to 4000 cases per annum in England and Wales [4]. MSCC maybe a feature of advanced primary cancer particularly in cancers of breast, lung, and prostate, however it could be a presenting complaint in up to 20% of malignancies. Treatment in MSCC usually involves a multidisciplinary approach with use of corticosteroids, radiotherapy, and surgery all playing a role [5]. However, evidence has suggested that only 50% of patients have a positive response [6]. Multiple myeloma is a haematological malignancy that commonly involves the spine. Vertebral collapse and soft tissue extension of tumour into the spinal canal in multiple myeloma may cause neurological deficit and mechanical instability leading to pain and deformity. Although the primary treatment of myeloma is usually oncological, this case illustrates the successful use of surgery, in a patient who presented with neurological deficit. 2. Case Report A 46-year-old gentleman presented with increasing back pain and pain in the left hip for six months. This pain was associated with numbness in the left leg. Over the previous two weeks, his symptoms had become intrusive, resulting in an ability to walk only with the aid of crutches. The patient reported of no weight loss and no bowel or bladder dysfunction. Clin. Pract. 2021, 11, 124–130; doi:10.3390/clinpract11010018 www.mdpi.com/journal/clinpract Clin. Pract. 2021, 11 125 Clin. Pract. 2021, 11, FOR PEER REVIEW 2 On examination, there was tenderness in the lower thoracic spine, lumbar spine, and over the On examination, there was tenderness in the lower thoracic spine, lumbar spine, and over the iliac crest on the left side. Neurological examination revealed reduced sensation over the left leg from iliac crest on the left side. Neurological examination revealed reduced sensation over the left leg from the groin to the foot. Power was reduced in left toe extension and left ankle dorsiflexion to Medical the groin to the foot. Power was reduced in left toe extension and left ankle dorsiflexion to Medical Research Council (MRC) grading of 3/5. On the right side, sensation was reduced over the little toe. Research Council (MRC) grading of 3/5. On the right side, sensation was reduced over the little toe. Reflexes were bilaterally brisk in the lower limbs, but plantar reflex was normal. Reflexes were bilaterally brisk in the lower limbs, but plantar reflex was normal. Full blood count, erythrocyte sedimentation rate (ESR) and calcium levels were normal. Computed Full blood count, erythrocyte sedimentation rate (ESR) and calcium levels were normal. tomography (CT) scanning revealed multiple areas of bony destruction in the vertebrae and left iliac Computed tomography (CT) scanning revealed multiple areas of bony destruction in the vertebrae bone. (Figure1) Magnetic resonance imaging (MRI) revealed destruction of T5, T10, L3, and L5 and left iliac bone. (Figure 1) Magnetic resonance imaging (MRI) revealed destruction of T5, T10, L3, vertebrae with abnormal tissue causing severe compression of the spinal cord and nerves in these areas and L5 vertebrae with abnormal tissue causing severe compression of the spinal cord and nerves in (Figure2). these areas. (Figure 2) FigureFigure 1.1.CT CT scan scan of of the the spine spine and and pelvis pelvis highlighting highlighting multiple multiple areas ofareas bony of destruction bony destruction in the thoracic in the andthoracic lumbar and vertebrae. lumbar vertebrae. (blue arrows) (blue Therearrows) is There a large is mass a large in themass left in iliacthe left bone. iliac (green bone.arrow). (green arrow). Clin. Pract. 2021, 11 126 Clin. Pract. 2021, 11, FOR PEER REVIEW 3 (a) (b) FigureFigure 2.2. (a): T2 T2-weighted-weighted sagittal sagittal sequence sequence MRI MRI scan showing an epidural softsoft tissuetissue tumourtumour compressingcompressing thethe spinalspinal cordcord (blue(blue arrow);arrow); ((bb):): T2-weightedT2-weighted axialaxial sequencesequence MRIMRI scanscan atat T10T10 showingshowing markedmarked compressioncompression ofof thethe spinalspinal cordcord fromfrom aa softsoft tissuetissue tumourtumour(blue (bluearrow). arrow) PlasmaPlasma electrophoresiselectrophoresis waswas performedperformed toto checkcheck forfor multiplemultiple myeloma.myeloma. This revealedrevealed thatthat IgAIgA andand IgMIgM levelslevels werewere normal.normal. However an abnormal band was detected on plasma electrophoresis. FurtherFurther analysis revealed revealed an an excess excess of ofkappa kappa light light chains chains with with a value a value of 200. of5 200.5mg/L mg(normal/L (normal value value3.3–19 3.3–19.4)..4). Free lambda Free lambdachain values chain were values normal. were normal.These tests These suggested tests suggesteda diagnosis a of diagnosis BJP-kappa of BJP-kappamyeloma. myeloma. TuberculosisTuberculosis can can presentpresent similarlysimilarly toto MSCC,MSCC, inin thatthat spinalspinal canalcanal involvementinvolvement cancan causecause radiatingradiating painpain andand limblimb weaknessweakness [7[7]].. It was,was, however,however, anan unlikelyunlikely didifferentialfferential diagnosis.diagnosis. TheThe typicaltypical manifestationsmanifestations ofof spinalspinal tuberculosistuberculosis involveinvolve vertebralvertebral bonebone destruction,destruction, narrowingnarrowing ofof intervertebralintervertebral discdisc spacespace andand paraspinal paraspinal abscess abscess [7 [7]]. Despite. Despite MRI MRI revealing revealing vertebral vertebral bone bone destruction, destruction, there there was was no evidenceno evidence of paraspinal of paraspinal abscess. abscess. TheThe possibilitypossibility ofof osteomyelitisosteomyelitis waswas alsoalso ruledruled outout uponupon haematologicalhaematological testing.testing. ESRESR inin osteomyelitisosteomyelitis tendstends toto bebe raisedraised toto aa levellevel greatergreater thanthan 100100 mmmm/h/h [8[8]].. TheThe patient,patient, however,however, hadhad aa normalnormal ESRESR andand diddid notnot presentpresent withwith featuresfeatures ofof systemicsystemic infection.infection. PrimaryPrimary bonebone tumourstumours maymay aaffectffect thethe spinespine andand manifestmanifest withwith cordcord compression.compression. TheThe incidenceincidence ofof primaryprimary bonebone tumourstumours aaffectingffecting thethe spinespine isis reportedreported toto bebe betweenbetween 44 andand 13%13% [[9]9].. Boussios et al.,al., afterafter reviewreview ofof literature,literature, reportedreported onon 6969 casescases ofof Ewing’sEwing’s sarcomasarcoma aaffectingffecting thethe spinespine andand presentingpresenting withwith cord compression compression [10] [10.]. In Intheir their report, report, the theaverage average age of age the of patient the patient was younger was younger with a median with a medianage of 17.95 age ofyears. 17.95 Multiple years. Multiplemyeloma myelomais the most is common the most primary common bone primary tumour bone of tumourthe spine. of The the spine.multiple The vertebral multiple vertebralinvolvement involvement in this case in this would case wouldbe in befavour in favour of either of either metastatic metastatic disease disease or ormyeloma. myeloma. Lastly,Lastly, thethe probabilityprobability ofof MSCCMSCC waswas increasedincreased byby thethe presencepresence ofof bothboth motormotor andand sensorysensory symptoms.symptoms. Radicular Radicular pain pain and and sensory complaints tend to be initial symptomssymptoms inin patientspatients withwith lumbarlumbar metastases,metastases, whereaswhereas weaknessweakness inin thethe limbslimbs isis moremore pronouncedpronounced inin patientspatients withwith thoracicthoracic metastasesmetastases [[11]11].. As T5, T10, L3,L3, and L5 were all aaffected,ffected, itit waswas
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