Burak EREN, İlker GÜLEÇ, Feyza KARAGÖZ GÜZEY, Ece SAĞLAM, Azmi TUFAN, Murat KARACAN, Nuri Serdar BAŞ

Omurilik Basısı Nedeniyle Dekompresyon Uygulanan Multipl Miyelom Olgularının Değerlendirilmesi

Multipl miyelom omurilik kompresyonuyla ilişkili tüm kanserlerin % 5-10’ unu oluşturur. Bu çalışmada spinal epidural bası nedeniyle opere edilen multipl miyelom olan hastaların cerrahi sonuçlar değerlendirildi. 2011-2017 yılları arasında hastanemiz nöroşirurji kliniğinde omurilik basısı nedeniyle posterior girişimle dekompresyon yapılan ve patolojik tanısı multipl miyelom olan 21 hasta çalışmaya dahil edildi. Hastaların demografik, klinik ve radyolojik özellikleri incelendi. 21 hastanın yaş ortalaması 62.6±9,3' tü. Hastaların 13' ü erkek ve 8' i kadındı. Protein elektroferezinde zincir izotipine bakıldığında en fazla Ig G (%52.4) bulunuyordu. Hastaların Karnofsky performans değeri ortalama 46.2±17,7 idi. Hastaların ameliyat öncesine göre postoperatif motor güçlerinde belirgin iyileşme görüldü (p=0,0001). Ayrıca VAS skorlarına bakıldığında postoperatif ağrının belirgin olarak azaldığı tespit edildi (p=0,001). Hastaların %90’ ının acil şartlarda ameliyata alındığı görüldü. Ameliyat sırasında dekompresyona ilave olarak stabilizasyon yapılan hasta sayısı 5' ti (%23.8). Radyolojik veriler incelendiğinde opere edilen vertebra segmentindeki ortalama çökme miktarı oranı %33.1 ve tümörün spinal kanal çapını ortalama daraltma oranı %65.4 olarak hesaplandı. Tüm hastalarda spinal kanal çapında daralma olmasına rağmen, çökme kırığı 16 hastada (%76.2) vardı. Ortalama takip süresi 22.3 ay idi. İlk bir yılda 5 hasta olmak üzere, takip süresinde 9 hasta kaybedildi. Ameliyat sonrası komplikasyon olarak 2 hastada yara yeri enfeksiyonu, 1 hastada kronik böbrek yetmezliği ve 1 hastada da bilateral plevral efüzyon gelişti. Multipl miyelom nedeni ile omurilik basısı olan hastlarda ilerleyici nörolojik defisit varsa cerrahi tedavi ilk seçenek olmalıdır. Cerrahi tedavi ile omurilik basısının dekompresyonu, ağrı kontrolü ve stabilizasyonu yapılabilir.

Anahtar Kelimeler:

Multipl miyelom, vertebra tümörü, spinal kord basısı, spinal tümör

Evaluation of Multiple Myeloma Patients Performed Decompression Due to Spinal Cord Pressure

Multiple myeloma accounts for 5-10% of all cancers associated with spinal cord compression. In this study, the surgical results of patients with multiple myeloma operated for spinal epidural compression were evaluated. Between 2011 and 2017, twenty-one patients were operated by posterior decompression for spinal cord compression, whose pathological diagnosis was multiple myeloma in our hospital's neurosurgery clinic included in the study. Demographic, clinical and radiological features of the patients and their status after surgery were examined. The mean age of the 21 patients was 62.6 ± 9.3. Thirteen patients were male and 8 were female. When the chain isotype was found in protein electrophoresis, the maximum IgG (52.4%) was present. The mean Karnofsky performance of the patients was 46.2 ± 17.7. Significant improvement was observed in the postoperative motor strength of the patients (p = 0.0001). In addition, postoperative pain-VAS scores-was significantly reduced (p = 0.0001). 90% of the patients were operated under emergency conditions. The number of patients who were operated stabilization with decompression was 5 (23.8%). When the radiological data were analyzed, the mean amount of compression in the operated vertebrae was 33.1% and the mean shrinkage rate of the tumor was 65.4%. Although spinal canal narrowing was observed in all patients, compression fracture was present in 16 patients (76.2%). The mean follow-up period was 22.3 months. During the follow-up period, 9 patients died, 5 of them were in the first year. Postoperative complications were wound infection in 2 patients, chronic renal failure in 1 patient and bilateral pleural effusion in 1 patient. Surgical treatment should be the first option if there is a progressive neurological deficit in patients with spinal cord compression due to multiple myeloma. With surgical treatment, decompression of the spinal cord compression, pain control and stabilization can be performed.

Keywords:

Multiple myeloma, vertebra tumor, spinal cord compression, spinal tumor,

PDF

___

1. Anitha D, Baum T, Kirschke JS, Subburaj K. Risk of vertebral compression fractures in multiple miyeloma patients A finite-element study. Medicine (Baltimore). 2017; 96(2): e5825. doi: 10.1097/MD.0000000000005825.
2. Benson WJ, Scarffe JH, Todd ID, Palmer M, Crowther D. Spinal-cord compression in miyeloma. Br Med J. 1979; 1:1541–4.
3. Bilsky MH, Azeem S. Multiple Miyeloma: Primary bone tumor with systemic manifestations. Neurosurg Clin N Am. 2008; 19: 31–40.
4. Bird JM, Owen RG, D’Sa S, Snowden JA, Pratt G, Ashcroft J, Yong K, Cook G, Feyler S, Davies F, Morgan G, Cavenagh J, Low E, Behrens J. Guidelines for the diagnosis and management of multiple miyeloma 2011. Br J Haematol. 2011; 154: 32–75.
5. Blade J, Cibeira MT, Fernandez de Larrea C, Rosinol L. Multiple miyeloma. Ann Oncol. 2010; 21: 313–9.
6. Denaro V, Denaro L, Albo E, Papapietro N, Piccioli A, Di Martino A. Surgical management of spinal fractures and neurological involvement in patients with miyeloma. Injury. 2016; 47 (Suppl 4): 49-53.
7. Dürr HR, Kühne JH, Hagena FW, Moser T, Refior HJ. Surgical treatment for miyeloma of the bone. A retrospective analysis of 22 cases. Arch Orthop Trauma Surg. 1997; 116: 463–9.
8. Erdem E, Samant R, Malak SF, Culp WC, Brown A, Peterson L, Lensing S, Barlogie B. Vertebral augmentation in the treatment of pathologic compression fractures in 792 patients with multiple miyeloma. Leukemia. 2013; 7(12): 2391-3.
9. Flouzat-Lachaniette CH, Allain J, Roudot-Thoraval F, Poignard A. Treatment of spinal epidural compression due to hematological malignancies: a single institution’s retrospective experience. Eur Spine J. 2013; 22: 548–55.
10. Giuliani N, Ferretti M, Bolzoni M, Storti P, Lazzaretti M, Dalla Palma B, Bonomini S, Martella E, Agnelli L, Neri A, Ceccarelli F, Palumbo C. Increased osteocyte death in multiple miyeloma patients: role in miyelomainduced osteoclast formation. Leukemia. 2012; 26: 1391–401.
11. Guzik G. Oncological and functional results of the surgical treatment of vertebral metastases in patients with multiple miyeloma. BMC Surg. 2017; 17(1): 92. doi: 10.1186/s12893-017-0288-9.
12. Jung HA, Cho SH, Kim SJ, Jang JH, Kim WS, Jung CW, Kim K. Spinal cord compression in multiple miyeloma: a single center experience. Leuk Lymphoma. 2014; 55(10): 2395-7.
13. Kim SI, Kim YH, Ha KY, Lee JW, Lee JW. Surgical Roles for Spinal Involvement of Hematological Malignancies. J Korean Neurosurg Soc. 2017; 60(5): 534-9.
14. Loblaw DA, Mitera G, Ford M, Laperriere NJ. A 2011 updated systematic review and clinical practice guideline for the management of malignant extradural spinal cord compression. Int J Radiat Oncol Biol Phys. 2012; 84: 312–7.
15. Malhotra K, Butler JS, Yu HM, Selvadurai S, D'Sa S, Rabin N, Kyriakou C, Yong K, Molloy S. Spinal disease in miyeloma: cohort analysis at a specialist spinal surgery centre indicates benefit of early surgical augmentation or bracing. BMC Cancer. 2016; 16: 444. doi: 10.1186/s12885-016-2495-7.
16. Miller JA, Balagamwala EH, Chao ST, Emch T, Suh JH, Djemil T, Angelov L. Spine stereotactic radiosurgery for the treatment of multiple miyeloma. J Neurosurg Spine. 2017; 26(3): 282-90.
17. Nash Smyth E, Conti I, Wooldridge JE, Bowman L, Li L, Nelson DR, Ball DE. Frequency of skeletal-related events and associated healthcare resource use and costs in US patients with multiple miyeloma. J Med Econ. 2016; 19(5): 477-86.
18. Rades D, Douglas S, Veninga T, Poortmans P, Bajrovic A, Hoskin PJ, Rudat V, Schild SE. Prognostic factors for local control and survival in patients with spinal cord compression from miyeloma. Strahlenther Onkol. 2012; 188: 628–31.
19. Rades D, Panzner A, Rudat V, Karstens JH, Schild SE. Dose escalation of radiotherapy for metastatic spinal cord compression (MSCC) inpatients with relatively favorable survival prognosis. Strahlenther Onkol. 2011; 187:729–35.
20. Rehak S, Maisnar V, Malek V, Cesak T, Ryska P, Bartos M, Talab R. Diagnosis and surgical therapy of plasma cell neoplasia of the spine. Neoplasma. 2009; 56: 84–7.
21. van Rhee F, Bolejack V, Hollmig K, Pineda-Roman M, Anaissie E, Epstein J, Shaughnessy JD Jr, Zangari M, Tricot G, Mohiuddin A, Alsayed Y, Woods G, Crowley J, Barlogie B.. High serum-free light chain levels and their rapid reduction in response to therapy define an aggressive multiple miyeloma subtype with poor prognosis. Blood. 2007; 110: 827–32.
22. Wight J, Stillwell A, Morris E, Grant B, Lai HC, Irving I. Screening whole spine magnetic resonance imaging in multiple miyeloma. Intern Med J. 2015; 45(7): 762-5.
23. Wise JJ, Fischgrund JS, Herkowitz HN, Montgomery D, Kurz LT. Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine (Phila Pa 1976). 1999; 24: 1943–51.
24. Zhang J, Zhong Y. Spinal cord compression in multiple miyeloma: a single center experience. Leuk Lymphoma. 2014; 55(10): 2395-7.