Multiple myeloma and back pain.

Multiple myeloma is a rare cause of back pain that is often misdiagnosed in its early stages. It is a unique condition that can cause pain through several mechanisms, either individually or in combination. These mechanisms include stimulation of nociceptors by tumor compression, tumor products, and the host response to the tumor or its products.

Although the exact etiology of multiple myeloma is unknown, the following facts are known. There is a genetic predisposition to the development of myeloma. It is also known that radiation increases the incidence of the disease, as observed in survivors of the atomic bombing during World War II. RNA viruses are also involved in the development of multiple myeloma. The disease is rare in people under 40 years of age, with the average age of diagnosis being 60 years. There is a predisposition in males. In the Negroid race, the incidence of the disease is 2 times higher. In the world, the incidence of multiple myeloma is 3 per 100,000 people.

The most common manifestation of the disease is back and rib pain. It occurs in more than 70% of patients who are eventually diagnosed with the disease. The bone damage is osteolytic in nature and is better seen on non-contrast radiography than on radionuclide bone imaging. Pain with movement is noted, hypercalcemia is quite common, and is a significant symptom in many patients with multiple myeloma. Life-threatening infections, anemia, bleeding, and renal failure are often present in combination with the symptoms of pain. Increased blood viscosity, as a result of the action of tumor products, can lead to cerebrovascular complications.

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Symptoms of Multiple Myeloma

Widespread pain is a common clinical complaint that ultimately leads the physician to the diagnosis of multiple myeloma. Seemingly minor trauma may cause abnormal vertebral compression or rib fractures. Physical examination often reveals pain with movement of the affected bones, as well as a tumor mass on palpation of the skull or other affected bones. Neurologic signs of nerve compression due to tumor or fracture and cerebrovascular complications are often present. Positive Trousseau and Chvostek signs due to hypercalcemia may also be present. Anasarca due to renal failure is a poor prognostic sign.

Survey

The presence of Ben Jones protein in the urine, anemia and an increase in M protein TFI on serum protein electrophoresis indicate multiple myeloma. Classic "punched" lesions in the bones of the skull and spine on non-contrast radiography are pathognomonic for this disease. Due to the low osteoclastic activity in patients with multiple myeloma, a gradient nuclide study of bone with diffuse destruction may give a negative result. MRI is indicated for all patients suspected of having multiple myeloma with signs of spinal cord compression. All patients with multiple myeloma are indicated for serum creatinine determination, automated blood biochemistry, which includes determination of serum calcium.

Differential diagnosis of multiple myeloma

Many other bone marrow disorders, including heavy chain disease and Waldenström macroglobulinemia, can mimic the clinical picture of multiple myeloma. Amyloidosis also has many clinical features that are similar. Metastatic disease from prostate or breast cancer can also cause pathologic fractures of the spine and ribs and metastases to the cranial vault that may be mistaken for myeloma. Patients with benign monoclonal gammopathy, most of whom require no specific treatment, can have laboratory findings that mimic those seen in multiple myeloma.

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Treatment of multiple myeloma

Management of myeloma is aimed at treating progressive bone damage and reducing myeloma proteins in the serum. Both of these goals are achieved using radiation therapy and chemotherapy, alone or in combination. High-dose steroid pulse therapy has been shown to be effective in providing symptomatic improvement and prolonging life expectancy.

Treatment of pain in multiple myeloma should begin with NSAIDs or COX-2 inhibitors. The addition of opioids may be needed to control severe pain from pathological fractures. Orthotic devices such as Kesh bandages and rib belts may help stabilize the spine and should be considered for pathological fractures. Local heat and cold applications may also be effective. Repetitive movements that cause pain should be avoided. In patients who do not respond to these treatments, local anesthetics or steroids may be given intercostally or epidurally. In selected cases, spinal opioids may also be effective. Finally, radiation therapy is often required in cases of significant bone disease to provide adequate pain control.

Side effects and complications

About 15% of patients with multiple myeloma, despite aggressive therapy, die within the first three months after diagnosis. And another 15% - in each subsequent year. Common causes of death are renal failure, sepsis, hypercalcemia, bleeding, development of acute leukemia and stroke. Non-fatal complications, such as pathological fractures, significantly complicate the life of patients with multiple myeloma. Untimely recognition and treatment of such complications aggravate the patient's suffering and lead to early death.

Careful evaluation of patients with the triad: proteinuria, pain in the spine or ribs, and changes in serum electrophoresis

Belkov, is essential to prevent the inevitable complications of delayed diagnosis of multiple myeloma. Both physician and patient must understand that despite early treatment, most patients with multiple myeloma will die within 2 to 5 years of diagnosis. Epidural and intracostal injections of local anesthetics and steroids can provide good temporary relief of the pain associated with multiple myeloma.