title: Successful nonsurgical treatment for highly unstable fracture subluxation of the spine secondary to myeloma.
abstract: In multiple myeloma, patients may develop rapidly progressive, lytic, spinal lesions. These may result in spinal instability, but instrumented stabilization may fail because of poor bone quality. In addition, patients are immunocompromised and are therefore at increased risk of deep infection.
  
  
  
  The aim was to describe a patient presenting with an unstable fracture subluxation of the thoracic spine secondary to myeloma, successfully treated with non-surgical management.
  
  
  
  This is a case report of a patient seen in a specialist spinal myeloma service.
  
  
  
  A 74-year-old Caucasian woman presented with destructive myelomatous lesions of T9 and T10. Greater than 50% of the T9 vertebral body was involved, and there was subluxation and translation of T9 on T10 (Spinal Instability Neoplastic Score of 14). There was a single episode of transient paresthesia of both lower limbs. The patient was in considerable pain, requiring large quantities of opioid analgesia. She was treated non-surgically in a thoracolumbar sacral orthosis for a period of 3 months (strict bed rest for the first 3 weeks).
  
  
  
  A computed tomography scan at 3 months demonstrated bony fusion and the brace was removed. The patient returned to her normal activities 5 months posttreatment. Her pain and patient-reported outcome scores were significantly improved.
  
  
  
  We present a successful non-surgical management of an unstable myelomatous vertebral fracture without neurologic deficit. However, surgical stabilization remains the treatment of choice in unstable vertebral fractures and spinal surgical opinion should be sought in all cases.
authors.affiliation: Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK. Electronic address: karan@doctors.org.uk.
authors.forename: Karan
authors.initials: K
authors.lastname: Malhotra
authors.affiliation: Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
authors.forename: Darren F
authors.initials: DF
authors.lastname: Lui
authors.affiliation: Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Butler
authors.affiliation: Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
authors.forename: Susanne
authors.initials: S
authors.lastname: Selvadurai
authors.affiliation: Spinal Deformity Unit, Department of Spinal Surgery, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
authors.forename: Sean
authors.initials: S
authors.lastname: Molloy
mesh_terms: D000368:Aged; D001915:Braces; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D008159:Lumbar Vertebrae / Q000000981:diagnostic imaging; D009101:Multiple Myeloma / Q000150:complications*; D019637:Orthopedic Procedures; D016103:Spinal Fractures / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D013904:Thoracic Vertebrae / Q000000981:diagnostic imaging