Spinal Bracing: A Novel Non-Invasive Technique to Prevent Spinal Fractures and Preserve Spinal Stability in Patients with Multiple Myeloma
Authors: Kanellias Nikolaos , Wilson William , Xu Ke , Land Joanne , Parcharidou Agapi , Kyriakou Charalampia 
Published: December 2024

Introduction: Spinal involvement, a cardinal manifestation of multiple myeloma (MM) bone disease has been identified as a significant prognostic factor for inferior survival. A subgroup of patients with spinal disease and vertebral fractures were traditionally managed with either minor or major surgical intervention for spinal stability. The literature on conservative management of MM spinal disease using a spinal brace to maintain spinal stability, offer pain relief and prevent spinal deformity is very limited.

The aim of this retrospective study was to explore the impact of spinal bracing (SB) on sustaining stability, prevention of new spinal fractures and the preservation of spinal alignment.

Methods: We retrospectively evaluated the electronic records of MM patients who were followed up in one hospital between 2018-2023 and had a spinal brace fitted.

Results: We identified 422 patients who had SB, 372 (88%) at diagnosis and 50(12%) at relapse. 211(50%) patients had a cervico-thoraco-lumbo-sacral orthosis (CTLSO) brace, 207 (49%) thoracic lumbar sacral orthosis (TLSO)and 4(1%) hard cervical collar. Indication for SB was spinal involvement (SPI) for 420(99%) patients. The remaining 2/422 (1%) patients had solely sternum involvement (STI) without spinal fractures (SF) or spinal lesions (SL).

Among the group of patients with SPI, 346(82%) had SF, 70(17%) SL and 4(1%) combination of SF and SL. 135/420(32%) patients with SPI had also STI; 94 (22%) had sternum lesions (STL), 46(11%) sternum fracture (STF) and 5(1%) combination of SPL and STF. The duration of SB was 3 months for 386(91%) patients.

At the time of SB 422(100%) patients experienced pain, 11(3%) had surgical interventions, while 67(16%) showed signs or symptoms of spinal cord compression and received radiotherapy. 78(18%) patients had spinal plasmacytomas. The backbone of treatment regimens were proteasome inhibitors and Immunomodulatory agents and 91% received bisphosphonates. The majority of patients (96%) showed radiological signs of new bone formation and spinal stability on imaging 3 months post SB and only 9(2%) showed imaging signs of progressive deformity. 28/422 (6.6%) patients showed radiological signs of worsening of preexisting fractures (25 at diagnosis and 3 at subsequent relapses) and 7/422(1.7%) experienced new fractures below the level of the brace. Only 3 patients who had a brace fitting at relapse, had previous surgical interventions at the same spinal level during previous lines of treatment. All worsening of pre-existing fracture events occurred within the first 4.3(1-4.3) months. Among this group of 35 patients, 18 had CTLSO and 17 TLSO brace and 29 required the brace for 3 months. 35 had spinal and 10 both spinal and sternum involvement. 9 patients were also treated with radiotherapy (3 for coexisting spinal plasmacytomas, 4 for neurological symptoms and 2 for spinal cord compression). In this group of patients 1 showed progressive deformity and 8 showed signs of new bone formation.

Conclusions: In this real-world study the majority of MM patients who present with pain and spinal involvement will have a spinal fracture and be managed conservatively with a spinal brace for 3 months. Early brace application was a safe, non-invasive method After a median follow up of 18 months the large majority of patients showed signs of new bone formation and spinal stabiility. However, a small percentage of patients developed a new fracture or worsening of pre-exisiting fracture within the first 4 months. This highlights the need for early intervention and repeat imaging if new or worsening pain occurs. None of the patients from this cohort with spinal instability required additional surgical interventions and the incidence of longer-term spinal deformity was low.