Management of Neoplastic Epidural Spinal Cord Compression in Multiple Myeloma

Diagnosis

Neoplastic epidural spinal cord compression is the most likely diagnosis in an elderly patient with anemia, hypercalcemia, renal dysfunction, and progressive thoracic back pain with neurologic findings, and is almost certainly secondary to multiple myeloma. 1

The classic laboratory triad for multiple myeloma—severe normocytic anemia, hypercalcemia, and renal dysfunction—strongly points toward a plasma‑cell neoplasm. 1
Renal impairment (elevated creatinine, reduced eGFR) is consistent with myeloma‑related kidney disease. 2
Age 65–70 years represents the peak incidence window for multiple myeloma. 1
Sub‑acute progression of back pain over several weeks, worsening in intensity, is typical of metastatic spinal disease. [3][4]
Night‑time pain is a red‑flag symptom indicating possible malignancy. [3][4]
A radicular pain pattern with sensory loss at the T10 dermatome suggests nerve‑root involvement from epidural compression. [5][6]
Bilateral positive straight‑leg‑raise test indicates significant canal compromise. 5

Magnetic resonance imaging (MRI) of the thoracic spine with and without intravenous contrast is the preferred imaging modality to confirm epidural spinal cord compression and delineate vertebral involvement. The American College of Radiology (ACR) Appropriateness Criteria rate MRI as “usually appropriate” for thoracic back pain with myelopathy or radiculopathy, specifically highlighting neoplastic etiologies. [5][6]7

Serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP) should be obtained to detect a monoclonal protein, as recommended by the National Comprehensive Cancer Network (NCCN). [1][2]
Serum free‑light‑chain assay is advised for further characterization of the monoclonal gammopathy. 2
A complete skeletal survey or whole‑body low‑dose CT is indicated to identify lytic bone lesions typical of myeloma. 1
Bone‑marrow biopsy is required to confirm the diagnosis of multiple myeloma when laboratory and imaging findings are suggestive. 1

Immediate neurosurgical and oncology consultation is essential for patients with neurologic deficits (e.g., sensory loss at T10) and rapidly progressive symptoms, because delayed treatment of epidural spinal cord compression can result in irreversible paralysis. [5][3]