Case Study: Multiple Thoracic Compression Fractures in a Young Female with Suspected Myeloma

Case at a Glance

A 31-year-old female with a history of hypermobility and chronic pain presented with an acute exacerbation of mid-back pain. Imaging revealed multiple non-traumatic thoracic compression fractures, leading to an investigation for an underlying pathological cause, with suspicion for multiple myeloma.

Patient's Story

A 31-year-old female initially experienced mild mid-back pain for several weeks. Due to a complex medical history involving chronic pain, she didn't initially attribute it to a specific injury. However, the pain acutely worsened two days prior to her emergency department visit, becoming so severe that it left her unable to sleep. She described a sensation of being unable to fully straighten her back and noted that any twisting or leaning-back motion caused excruciating pain. She mentioned a personal history of hypermobility, which she felt contributed to a natural hyperextension in her spine.

Initial Assessment

Upon presentation to the emergency department, the patient was in significant distress due to severe mid-thoracic back pain. The pain was localized to the upper and middle thoracic spine and radiated anteriorly, wrapping around her rib cage. Physical examination revealed profound tenderness over the thoracic spinous processes. Her range of motion was severely limited by pain, particularly with extension and rotation of the spine. Her history was notable for the absence of any significant trauma that would explain the severity of her condition.

The Diagnostic Journey

An initial CT scan performed a month prior for the mild back pain had already identified superior endplate compression fractures at T1, T2, T3, and T5. Repeat imaging in the emergency department confirmed the fractures at T3 and T5 were stable but showed no signs of healing.

Clinicians noted the atypical nature of these fractures in a 31-year-old without a history of major trauma, and their location in the upper thoracic spine was also considered unusual. The diagnostic workup was broadened to search for a pathological cause. The patient reported she had also undergone an MRI which confirmed the fractures. Blood work had revealed abnormal serum free light chains, prompting an urgent referral to an oncologist to rule out multiple myeloma. Additionally, imaging had incidentally discovered two tumors on the L4 and L5 vertebrae, which were considered likely benign but added to the complex clinical picture.

Final Diagnosis

Multiple non-traumatic pathological compression fractures of the thoracic spine (T1, T2, T3, T5), secondary to an undiagnosed underlying systemic condition, highly suspicious for a plasma cell dyscrasia such as multiple myeloma.

Treatment Plan

In the emergency department, management was focused on pain control. A discussion was held regarding conservative management strategies. While the evidence for bracing to promote healing is inconclusive, the use of a thoracic brace was considered for symptomatic relief and to provide postural support.

The cornerstone of the treatment plan, however, is the urgent outpatient investigation by an oncology team. The primary goal is to establish a definitive diagnosis for the underlying cause of the bone fragility and initiate systemic treatment, which is critical for preventing further fractures and managing the disease.

Outcome and Follow-up

The patient was discharged from the emergency department with ongoing severe pain and significant functional limitations. The immediate focus remains on managing her symptoms while awaiting a comprehensive oncological evaluation. The long-term prognosis is entirely dependent on the findings of the oncology workup and the successful treatment of the underlying pathology. This case highlights the importance of considering pathological causes for fractures that are inconsistent with a patient's age and mechanism of injury.