Treatment approaches for multiple Myeloma vertebral column lesions - Results from an international survey distributed to the AO spine knowledge forum tumor

Abstract

Introduction: Vertebral fractures and epidural compression are common complications in Multiple Myeloma (MM). Although non-surgical management is generally preferred, internationally accepted management guidelines are lacking. This study aimed to assess current international treatment approaches and clinical conditions guiding decision-making in MM vertebral lesions.

Research question: Assessing international treatment standards for MM vertebral column lesions.

Material and methods: A survey was distributed to members of the AO Spine Knowledge Forum Tumor, an expert forum specialized on the treatment of oncologic spine disease. The survey consisted of 25 questions, of which 15 assessed the participant's background, clinical expertise, and experienced treatment standards regarding MM vertebral lesions, followed by ten fictional case examples with seven possible treatment scenarios each.

Results: 51 international experts completed the survey, 51 % being of orthopedic, and 44 % of neurosurgical background, while 5 % were radio-oncologists. 84 % of the participants stated they "see vertebral lesions in MM in general as a non-surgical disease". As strongest indicators to perform surgery, neurological deficits (74 %), and potentially unstable lesions (20 %) were chosen. Clinical and radiological follow-up is performed by 83 %, however only in 46 % at defined intervals. 89 % would choose "less invasive" surgical strategies in MM than in similar lesions related to metastatic spine disease.

Discussion and conclusion: The participating experts agreed towards a more restrained and less invasive management of MM patients, however the applicability of surgical scores, standards for follow-up, and indications as well as surgical strategies for MM vertebral lesions varied widely, illustrating the need for international guidelines standardizing treatment.

Keywords: Chronic vertebral pain; International treatment standards; Multiple Myeloma; Surgical decision-making; Vertebral column lesions.

Fig. 1

General characteristics of the survey participants, with A) geographical localization, B) associated health-care sector, C) specialty background, D) treated spinal oncology cases per year, E) association to a specialized cancer center. Values are given in total numbers (n) and percentage (%), with n = 51 equaling 100 %.

Fig. 2

Examples of the participant's answers regarding their perceived treatment standards for Multiple Myeloma vertebral column lesions, with answers to the questions A) “Do you see vertebral lesions in MM in general as a “non-surgical” disease?, B) “Would you treat MM patients differently than patients with spinal metastases from solid cancer?”, C) “Who is primarily in charge of managing MM patients at your institution?” D) “What are the main reasons for interdisciplinary discussion of MM patients?”, E) “In your opinion, what would be the strongest indicators for surgery in vertebral lesions due to MM?”, F) “Do you routinely apply scoring systems to guide management of vertebral lesions in MM patients?”, G) “Do you use routine radiological follow-up on MM patients with asymptomatic vertebral lesions?” and H) “In MM cases where you would consider spine surgery, which techniques would you try to avoid?”. Values are given in percentage (%), with n = 51 equaling 100 %.

Fig. 3

Odd's Ratio of factors associated with the participant's answers. A) to the question if they “see vertebral lesions in Multiple Myeloma in general as a “non-surgical” disease?”, B) to the question if they “would treat Multiple Myeloma patients differently than patients with spinal metastases from solid cancer”. Odd's Ratio is given from −1 to +1, calculated using R with R studio.

Fig. 4

Ten exemplary, fictional case examples to assess the participant's perceived treatment standards for Multiple Myeloma vertebral column lesions, with the expert's treatment choices displayed in a tart chart. Values are given in %, with n = 51 equaling 100 %.