Histological evaluation of biopsies obtained from vertebral compression fractures: Unsuspected myeloma and osteomalacia

Study Design. A histological evaluation of biopsies obtained from presumed osteoporotic vertebral compression fractures (VCF) to confirm possible osteomalacia after tetracycline labeling. Objective. To describe the results of a series of biopsies obtained at the time of vertebral augmentation in presumed osteoporotic VCF, with special reference to the presence of unmineralized bone ( osteomalacia) and occult or unconfirmed plasma cell dyscrasia. Summary of Background Data. Vertebral augmentation is now widely performed as a method to treat osteoporotic or osteolytic VCF. However, the influence of underlying pathology on the effect of treatment is unclear. Methods. As of October 2003, 178 biopsies were obtained from 142 patients with VCF during 246 kyphoplasty procedures. There were 110 one-level, 28 two-level, and 4 three-level biopsies. Patients included 41 men and 101 women, with an average age of 72 years ( range 40 - 90). The patients consented to this procedure, and 25 received tetracycline (1g/day, in 2 doses separated by 6 days). Vertebral body biopsies were taken using a trephine just before the kyphoplasty procedure. The biopsies were fixed, embedded, and stained with toluidine blue and hematoxylin eosin, and were viewed with transmitted light. Unstained sections were viewed under fluorescent light to detect tetracycline labels. Results. The 178 biopsy levels included: T4 ( 3), T5 ( 1), T6 ( 4), T7 ( 13), T8 ( 12), T9 ( 8), T10 ( 11), T11 ( 17), T12 ( 28), L1 ( 25), L2 ( 14), L3 ( 13), L4 ( 17), and L5 ( 12). All specimens showed fragmented bone with variable amounts of unmineralized bone ( osteoid), suggesting bone remodeling and/or fracture healing. Woven bone and cartilaginous tissue were often present, representing fracture callus formation. The biopsies obtained from 30 patients (21%), including 4 who received tetracycline, showed significantly increased osteoid, suggesting either increased bone remodeling activity or mineralization defect ( osteomalacia). One sample from these 4 patients who received tetracycline showed no tetracycline labels, essentially diagnostic of osteomalacia. The biopsies also provided definitive diagnoses for one case of unsuspected and 3 cases of unconfirmed plasma cell dyscrasia. Conclusions. The majority of biopsies from this series of patients revealed findings consistent with various stages of fracture healing. Osteoid seams were increased in 30 patients, representing either increased bone remodeling or osteomalacia. More cases with tetracycline labeling will help elucidate the true incidence of osteomalacia in this population. As we confirmed 4 cases of plasma cell dyscrasia, we advocate a biopsy during each first-time vertebral augmentation procedure.