Percutaneous cementoplasty has been used for symptomatic pain relief in insufficiency and pathologic fractures of long bones as an adjunct to orthopedic surgery. Herein, we describe a case of percutaneous cementoplasty of the glenoid in a patient with multiple myeloma and a focal lesion. Following the procedure, the patient experienced immediate pain relief and improvement in shoulder mobility. Percutaneous cementoplasty may hold promise in the symptomatic pain relief for patients with focal osteolytic lesions related to primary or metastatic disease of the bones other than the axial skeleton.
Institutional review board approval was not needed for a retrospective case analysis at our institution. A 62-year-old man diagnosed with stage IIIA multiple myeloma presented with pain in the right shoulder, which was not relieved with analgesics. Whole-body positron emission tomography (PET)–computed tomography (CT) performed in August 2006 revealed a single 1.2-cm focal lesion involving the right glenoid with a standardized uptake value of 2.3 by lean body mass. No extramedullary disease was seen. There was no evidence of infection.
This was followed up with a CT scan of the right shoulder, which revealed a 1.2-cm lytic lesion involving the right glenoid without evidence of glenohumeral or acromioclavicular joint compromise. There was no evidence of pathologic fracture or cortical disruption. The soft tissues were intact with no evidence of any joint effusion or any inflammatory changes within the soft tissues.
The patient reported a pain level of 3 on a visual analog scale, and the score increased to 5 with activity. Because many patients with multiple myeloma are referred to our department for vertebroplasty and cement injection into painful focal pelvic lesions, it was decided to pursue cementoplasty of the glenoid.
The risks and benefits of the procedure were discussed with the patient, and informed consent was obtained. The patient was prepared and draped in a sterile fashion. The procedure was performed with local anesthesia under CT guidance. The right glenoid was localized and, after anesthetizing the tract, an 18-gauge needle was advanced into the lesion. After CT confirmation of the optimal position of the needle in the cavity, cement was injected with subsequent scans intermittently (Figure). A total of 1.5 mL of polymethylmethacrylate bone cement was deposited into the cavity. There was no extravasation. There were no complications.
Immediately following the procedure, the patient reported relief of pain, with a score of 0 on the visual analog scale. The patient continued to receive therapy for the myeloma following our procedure.
Follow-up PET-CT performed 2 months after the procedure demonstrated nonvisualization of the previous right glenoid lesion. At follow-up 15 months later, the patient reported no pain, with a score of 0 on the visual analog scale in the region of the right shoulder.
In patients with multiple myeloma, pain is common and all efforts to alleviate this pain should be made. The most severe pain reported by patients with myeloma, however, comes from bone fractures—including microfractures. The myeloma deposits begin in the marrow, causing a dull, aching pain. If the lesion grows further, it can reach the periosteum, which is nerve-rich, causing a periodic shooting, burning sensation.
Percutaneous cementoplasty has been performed previously in pathologic fractures (1), including metastases (2). The pain relief achieved with glenoidoplasty may be derived from several mechanisms. One theory posits that motion among fractured microfragments is responsible for pain. Cement injected into the hollows of the thinned trabeculae gives structural reinforcement and aggregates the microfracture fragments into a singular block. Immobilization of the microfracture fragments may result in decreased motion and, thus, decreased pain. Secondarily, reinforcement of weakened bone may prevent further fracturing and collapse, which would be an additional source of pain. Alternatively, it is theorized that exothermia during cement hardening is believed to result in neurolysis of pain fibers, resulting in relief. PET was performed with fluorine 18 fluorodeoxyglucose, which showed an active lesion in the right glenoid process. Thus, this lesion was likely the cause of pain in this patient. The PET and magnetic resonance (MR) studies obtained after the treatment also revealed no more hyperintensity in the glenoidal region on short-inversion-time inversion-recovery MR images or active focal PET standardized uptake values.
We propose that percutaneous cement injection can help alleviate pain in lesions from multiple myeloma in locations other than the axial skeleton.
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