Multiple Myeloma: Take Elderly Bone and Back Pain Seriously

Don't Dismiss Persistent Bone or Back Pain in Seniors

Persistent and unexplained bone or back pain in the elderly is often dismissed as a normal part of aging. However, orthopedic and spine specialists warn that it could be a sign of a serious and potentially fatal disease called Multiple Myeloma. This condition arises from the uncontrolled growth of plasma cells in the bone marrow, leading to significant bone weakening, pathological fractures, and severe spinal problems.

Multiple Myeloma primarily affects individuals over 60, though it is extremely rare in children. It is common for orthopedic clinics to see elderly patients complaining of chronic back or bone pain, or experiencing fractures without significant injury. Compression fractures in multiple vertebrae or osteolytic lesions seen on imaging can point towards Multiple Myeloma. Dismissing these symptoms as common arthritis or osteoporosis can be life-threatening.

Key Diagnostic Signs: The CRAB Syndrome

A mnemonic called CRAB is used to identify the four main clinical signs of Multiple Myeloma. These include C - Hypercalcemia (abnormally high calcium levels in the blood), R - Renal impairment (decreased kidney function), A - Anemia (low red blood cell count), and B - Bone disease. Hypercalcemia can cause excessive thirst, constipation, weakness, and confusion.

Symptoms of anemia include fatigue, shortness of breath, and pale skin. Additionally, recurrent infections and an abnormally high ESR (Erythrocyte Sedimentation Rate) in the blood can also be significant indicators of myeloma. These symptoms should not be ignored, attributing them solely to old age or other common ailments.

Severe Impact on the Spine

The spine is one of the most commonly affected areas by Multiple Myeloma. Tumor growth weakens the vertebral structure, leading to compression fractures, severe pain, and kyphosis (abnormal forward curvature of the spine). If the myeloma spreads to the epidural space, it can put pressure on the spinal cord or the cauda equina.

New weakness in the legs, numbness, decreased sensation, saddle anesthesia (numbness in the groin and genital area), or changes in bladder and bowel control are emergency signs of neurological compression. In such cases, an immediate MRI scan and consultation with a specialist neurologist or spine surgeon are critical. Failure to address these symptoms promptly can result in severe complications such as permanent paralysis.

Investigation and Diagnosis Process

When Multiple Myeloma is suspected, the primary goal of investigations is not only to confirm the disease but also to assess its impact on bones, kidneys, and other vital organs. Routine blood tests may include a Complete Blood Count (CBC), ESR/CRP, calcium levels, creatinine and eGFR assessment, and total protein and albumin levels.

Specific tests for identifying myeloma, such as Serum Protein Electrophoresis (SPEP), serum immunofixation, serum free light chains, and quantitative immunoglobulins, are important. In some cases, urine protein electrophoresis and immunofixation may also be required. Low-dose whole-body CT scans, PET-CT, or whole-body MRI can be used to determine the extent of the disease. If neurological symptoms are present, an MRI of the spine is prioritized.

A bone marrow biopsy and examination are performed for definitive confirmation. The treatment of Multiple Myeloma demands a multidisciplinary approach, involving orthopedic surgeons, hematologists, and oncologists working together.

Multidisciplinary Treatment Approach

Orthopedic treatment focuses on managing the patient's pain, handling fractures, addressing mechanical instability, and relieving neurological compression. This may include pain management, appropriate activity adjustments, the use of bracing, bone-strengthening medications (like bisphosphonates), and, in select cases, radiotherapy.

For painful vertebral fractures, procedures like vertebral augmentation (e.g., kyphoplasty or vertebroplasty) can help support the vertebrae and reduce pain. If the disease causes severe instability, pathological fractures, or significant neurological compression, surgeries such as surgical decompression and spinal fusion may be necessary.

Experts emphasize that vertebral fractures accompanied by back pain, especially with symptoms like anemia, kidney dysfunction, or hypercalcemia, should not be attributed solely to osteoporosis or general spinal degeneration. Thorough investigation for the possibility of Multiple Myeloma is essential. Persistent and unexplained bone or back pain in seniors, fractures from minor injuries, or any signs of the CRAB syndrome should be taken seriously and undergo timely medical evaluation.