title: Pathologic sternal involvement is a potential risk factor for severe sagittal plane deformity in multiple myeloma with concomitant thoracic fractures.
abstract: BACKGROUND
  Skeletal involvement is observed in almost 80% of patients presenting with symptomatic multiple myeloma (MM). The vertebral column is the most frequently affected site by myeloma-induced osteoporosis, osteolysis, and compression fractures. Multiple pathologic compression fractures can lead to significant spinal deformity, which is often considered for complex reconstruction because of the poor quality of life for the affected patients.
  
  
  OBJECTIVE
  This study aimed to compare the clinical and radiological outcomes of two groups of MM patients; the first group had thoracic spine fractures and a concomitant pathologic sternal fracture (SF), and the second group had thoracic fractures but no sternal fracture (NSF).
  
  
  METHODS
  This was a cross-sectional study.
  
  
  METHODS
  The sample comprised 98 consecutive patients (n=98) with symptomatic MM and concomitant pathologic thoracic spine fractures over a 3-year period at a national tertiary referral center for the management of MM with spinal involvement.
  
  
  METHODS
  Clinical outcome measures used included European Quality of Life-5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), and visual analogue scale (VAS) pain score.
  
  
  METHODS
  All consecutive patients with MM were enrolled. The cohort was split into two patient groups: patients with SFs (SF group) and patients without sternal fractures (NSF group). Clinical, serologic, and pathologic variables, radiological findings, treatment strategies, and outcome measures were collected.
  
  
  RESULTS
  The SF group was younger (58±13 years vs. 66±11 years [p=.008]) when compared with the NSF group. The SF group presented with a greater thoracic kyphosis (73°±18° vs. 53°±17.5° [p=.005]), similar VAS pain scores (50.6±22.1 vs. 54.4±22.5 [p>.05]), but poorer EQ-5D (0.24±0.13 vs. 0.48±0.23 [p<.001]) score and ODI (60.6±10.3 vs. 48.2±17.8 [p=.013]) when compared with the NSF group.
  
  
  CONCLUSIONS
  Pathologic SF in an MM patient with thoracic compression fractures is a potential risk factor for the development of a severe thoracic kyphotic deformity and sagittal malalignment. This has been demonstrated in this study to be associated with a very poor health-related quality of life. A greater awareness of sternal myeloma disease is needed at presentation (the time of the primary survey) so that SFs can be potentially avoided, thereby preventing progression to a severe kyphotic deformity.
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK. Electronic address: josephsbutler@hotmail.com.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Butler
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
authors.forename: Karan
authors.initials: K
authors.lastname: Malhotra
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
authors.forename: Anand
authors.initials: A
authors.lastname: Patel
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
authors.forename: Mathew D
authors.initials: MD
authors.lastname: Sewell
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
authors.forename: Adam
authors.initials: A
authors.lastname: Benton
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK; Department of Haematology, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
authors.forename: Charalampia
authors.initials: C
authors.lastname: Kyriakou
authors.affiliation: Myeloma Spinal Service, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK.
authors.forename: Sean
authors.initials: S
authors.lastname: Molloy
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D050815:Fractures, Compression / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009101:Multiple Myeloma / Q000150:complications*; D011859:Radiography; D013121:Spinal Curvatures / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D013249:Sternum / Q000000981:diagnostic imaging / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging / Q000601:surgery
keywords: Kyphosis; Multiple myeloma; Sagittal plane; Spinal deformity; Sternum; Thoracic fractures