Cervical Spinal Injury as a Presentation of Multiple Myeloma: A Case ReportLeon Smith, Vicky Li and Simon ChanRehabilitation and Aged Care Services, Hornsby Ku-Ring-Gai Hospital, Hornsby 2077, NSW AustraliaKeywordsCase Report Spinal Injury Multiple MyelomaAbstractSpinal cord injury is a devastating complication of cancers that exert physical compression on the spinal cord. Multiple myeloma is known predominantly as a condition that involves bony structures and can manifest with complications such as pathological fractures. However, involvement of other structures including the CNS or the spinal cord is a possible complication, with potentially catastrophic consequences. We describe a case of multiple myeloma presenting initially as spinal cord compression in a 79-year-old man.IntroductionMultiple myeloma is a condition characterized by malignant proliferation of plasma cells, with production of monoclonal immunoglobulin (most commonly of the IgG variety), affecting over 100 000 individuals worldwide per year(1). Approximately 2500 Australians are diagnosed with multiple myeloma every year(2). Median age at diagnosis in Australia is 67, and 60% of patients are male(3). Initial treatment in Australia usually consists of bortezomib based treatments, with the most common first line regimen being bortezomib, cyclophosphamide, and dexamethasone(3). Overall survival from diagnosis is averages approximately 5 years(3).Interactions between malignant plasma cells and osteocytes results in decoupling of bone absorption and formation, mediated through a number of pathways including RANK/L, OPG and Wnt, which leads to the presence of lytic bone lesions(4). Pathological fractures can result from skeletal disease; as such, skeletal surveillance is recommended in multiple myeloma and pathological fractures are a potential complication of skeletal disease(1). However, involvement of other organ systems by expansion of myeloma lesions is also a potential complication, with severe consequences. In the case of the spinal cord, compression from vertebral myeloma can lead to significant neurological compromise and functional impairment(5,6).We describe a case of multiple myeloma of T1 resulting presenting with severe paraplegia in a previously healthy 79-year-old man.Case PresentationA 79-year-old Caucasian man presented to the emergency department of his local hospital with a 4 week history of atraumatic thoracic back pain, localized between the scapulae, complicated by acute-onset paraplegia in the preceding 48 hours. He described 2 days of lower leg weakness and difficulty mobilizing with an unsteady gait, before developing severe lower limb weakness and inability to mobilise. At the time of presentation, he reported no bladder or bowel incontinence. He reported about 6 kg of unintentional weight loss in the preceding 4 weeks, and some months of atraumatic right elbow pain.His only medical history was hypertension and stable coronary artery disease. His medications at the time of presentation were rosuvastatin 20 mg daily, metoprolol 25 mg twice daily, amlodipine 5 mg daily, aspirin 100 mg daily, and Olmesartan 20 mg daily. He lived with his partner, had never smoked and consumed an average of 2 standard drinks of alcohol per night.On examination in the emergency department, he had MRC grade 5/5 power bilaterally in the upper limbs, but grade 0 in all movement in the lower limbs. Reduced sensation to light touch was present below the level of the umbilicus. Reflexes were absent in the left lower limb, and only the patellar reflex was present in the right lower limb. No anal tone was apparent on digital rectal exam. Saddle anaesthesia was also present.An urgent CT scan in emergency revealed a T1 vertebral lesion with involvement of the vertebral body and posterior elements with epidural extension causing severe canal narrowing, and numerous bony lesions suggestive of myeloma. The patient was urgently transferred to the nearest tertiary referral centre for neurosurgical involvement. A spinal MRI performed upon arrival confirmed the presence of severe cord compression at the T1 level, with complete infiltration of the T1 vertebra, and pathological T1 fracture with 50% loss of body height (Figure 1). An urgent posterior cervical decompression and fusion occurred within 12 hours of presentation.