Figure 1. Anteroposterior radiograph of thoracic compression fracture.
Figure 2. Lateral view of thoracic compression fracture.
Figure 3. Sagittal MRI image revealing edema at T11.
A 65-year-old man presents with mid-back pain that has been present for a month. He believes the pain started after a standing height fall on his icy driveway. At the time, he had mild back pain but was able to walk away from the fall without trouble. The back pain has been moderate and slightly progressive over the last month. His back pain is worse with bending, squatting, and lifting. Radiographs reveal a thoracic compression fracture at T11 (Figures 1 and 2). Sagittal magnetic resonance imaging (MRI) (Figure 3) reveals edema in the T11 vertebral body consistent with an acute compression fracture. The patient completes dual-energy X-ray absorptiometry (DEXA) scans, which show that he has normal bone density at the hip and lumbar spine. Laboratory evaluation shows that parathyroid hormone, 25 (OH) vitamin D, complete metabolic panel, and complete blood cell count are all within normal limits. He denies a history of known cancer.
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This patient sustained a low-impact vertebral fracture in the setting of normal bone density, which raises the suspicion of a pathologic fracture. The patient has normal intact parathyroid hormone, calcium, and vitamin D levels that rule out primary and secondary hyperparathyroidism. The most common primary bone malignancy and cause of a pathologic vertebral fracture is multiple myeloma.1,2
Multiple myeloma is an incurable B-cell lymphocyte malignancy characterized by proliferation and expansion of plasma cells in bone marrow.1 Symptoms can include fatigue and bone pain but many patients are completely asymptomatic. Bone involvement is seen in 70% to 100% of patients; a pathologic fracture is often the first sign of disease.1
Multiple myeloma is diagnosed when monoclonal proteins are found in the blood or urine. A serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) to detect these proteins should be ordered in patients with a suspected pathologic fracture of the vertebral spine in the absence of a known cause of metastatic disease.2 If the SPEP and UPEP are positive then a bone marrow biopsy is performed to confirm plasma cells in the bone marrow.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
1. Giorgi PD, Schirò GR, Capitani D, D’Aliberti G, Gallazzi E. Vertebral compression fractures in multiple myeloma: redefining the priorities during the COVID-19 pandemic. Aging Clin Exp Res. 2020;32(7):1203-1206. doi:10.1007/s40520-020-01590-4
2. Angtuaco EJ, Fassas ABT, Walker R, Sethi R, Barlogie B. Multiple myeloma: clinical review and diagnostic imaging. Radiology. 2004;231(1):11-23. doi:10.1148/radiol.2311020452