Sciatica as an atypical initial presentation of multiple myeloma: a case report
Ali Merza Juma1
, Qasim Shamtoot1, Maawa Merza Juma2, John Flood3
Contributions: (I) Conception and design: AM Juma, Q Shamtoot; (II) Administrative support: MM Juma, J Flood; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Vertebral involvement in multiple myeloma is a frequent cause of morbidity and is associated with severe pain, spinal deformity, and neurological compromise. While back pain is a common presenting feature, sciatica as an initial manifestation of multiple myeloma is extremely rare, particularly in patients without a history of trauma or osteoporotic risk factors. Recognizing such atypical presentations is crucial for timely diagnosis and management.
Case Description: A middle-aged male with no significant medical history presented with a two-month history of progressive sciatica radiating bilaterally to the lower limbs, without preceding trauma, fever, or infection. Imaging revealed multiple vertebral compression fractures, and laboratory studies demonstrated anemia, hypercalcemia, renal dysfunction, and elevated inflammatory markers. Bone marrow biopsy and serum protein electrophoresis confirmed the diagnosis of multiple myeloma. The patient was managed conservatively with analgesia, spinal bracing, and correction of metabolic abnormalities. Vertebroplasty was advised for long-term spinal stabilization, and he was subsequently referred for chemotherapy under hematology, nephrology, and oncology joint care.
Conclusions: This case emphasizes the importance of considering multiple myeloma in the differential diagnosis of persistent or atypical sciatica, especially in non-osteoporotic or younger individuals. Early recognition of such presentations allows for prompt investigation and multidisciplinary management, improving patient outcomes. Vertebroplasty remains a valuable adjunct in achieving pain relief and functional recovery in multiple myeloma-related vertebral fractures.
Keywords: Multiple myeloma (MM); sciatica; vertebral compression fractures; vertebroplasty; case report
Received: 18 October 2025; Accepted: 12 February 2026; Published online: 25 March 2026.
doi: 10.21037/acr-2025-292
Highlight box
Key findings
• Sciatica, though common as a benign musculoskeletal complaint, can rarely be the initial presentation of multiple myeloma (MM).
• The case highlights multilevel vertebral compression fractures as the underlying cause of radicular pain in MM.
• Vertebroplasty serves as a valuable adjunct for spinal stabilization and pain control in MM patients with refractory or severe vertebral fractures.
What is known and what is new?
• MM typically presents with bone pain, anemia, hypercalcemia, and renal impairment; sciatica is an extremely uncommon initial symptom.
• This case highlights sciatica as the first clinical presentation of MM in a middle-aged, non-osteoporotic patient, underscoring the need to consider hematologic malignancy in persistent or atypical cases of back pain.
What is the implication, and what should change now?
• Clinicians should maintain a high index of suspicion for MM in patients with unexplained or prolonged sciatica, especially when imaging shows vertebral abnormalities.
• Early multidisciplinary evaluation and consideration of vertebroplasty can improve diagnosis, pain control, and functional outcomes in patients with MM-related spinal involvement.
Introduction
Background
Multiple myeloma (MM) is a malignancy of plasma cells characterized by clonal proliferation of abnormal plasma cells within the bone marrow. Under normal conditions, plasma cells produce functional immunoglobulins; however, in MM, neoplastic plasma cells secrete non-functional monoclonal immunoglobulins known as “M-proteins” or “M-bands” reflecting the clonal nature of the disease. The cumulative effects of malignant plasma cells, inflammatory mediators, and monoclonal proteins result in anemia, hypercalcemia, nephropathy, osteolytic lesions, and end-organ damage (1).
MM accounts for approximately 10% of all hematological malignancies, with a median age at diagnosis of 69 years and fewer than 14% of cases occurring in individuals under 55. Epidemiological studies show higher rates among males and individuals of African ancestry compared to those of European descent (2-5). Bone involvement is seen in nearly 60% of patients at diagnosis due to an imbalance in bone remodeling characterized by increased osteoclastic activity without a corresponding rise in osteoblastic activity leading to osteolytic lesions and vertebral compression fractures (1,2,6).
Rationale and knowledge gap
Although bone pain and spinal cord compression are common presenting features of MM, sciatica, which is a neuropathic pain syndrome resulting from lumbosacral nerve root irritation is an exceedingly rare initial manifestation. Reported cases in the literature usually attribute such symptoms to isolated extramedullary plasmacytomas rather than systemic MM involvement. Consequently, MM is often diagnosed late, when the disease is already advanced (7-10). This highlights the need to consider MM in the differential diagnosis of persistent or unexplained sciatica, particularly when typical risk factors such as trauma or osteoporosis are absent.Furthermore, there remains limited literature addressing the diagnostic approach and management strategies for MM presenting with multilevel vertebral compression fractures that mimic benign musculoskeletal or degenerative conditions.
Objective
This case report aims to highlight sciatica as an atypical initial manifestation of MM in a middle-aged patient with no significant comorbidities or osteoporotic risk factors. It underscores the importance of maintaining a high index of suspicion for hematological malignancy in atypical presentations of sciatica and demonstrates how early multidisciplinary evaluation including hematology, radiology, and orthopedic input can facilitate prompt diagnosis and improve clinical outcomes. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-292/rc).
Case presentation
A middle-aged gentleman, without any significant medical history, presented to the emergency department with complaints of a several months’ history of severe radicular pain, radiating from the lower back down to the foot bilaterally. The pain was exacerbated by movement and relieved by rest. He further complained of paresthesia and dizziness. The patient had no known drug allergies. Past medical, surgical, and family histories were unremarkable.
The patient had no history of falls, syncope, trauma, fever, headache, blurred vision, constipation, urinary retention, or saddle anesthesia.
On examination, the patient was lying flat on the bed, and he was conscious, alert, and oriented with a Glasgow Coma Scale of 15/15. The patient had normal vital signs with a heart rate of 80 beats per minute, blood pressure of 125/75 mmHg, oxygen saturation of 98% on room air, a temperature of 37 ℃, and a respiratory rate of 14 breaths per minute. The abdomen was soft and lax, non-tender, with no peritoneal signs or organomegaly. On cardiorespiratory examination, there were no signs of respiratory distress, equal air entry bilaterally, with no added sounds. S1 and S2 were audible, with no associated murmurs. On lower limb examination, there was intact soft touch, sharp touch, vibration, power was 5/5, and normal reflexes (++). Gait could not be assessed because of the pain.
Following discussion with the emergency department team, investigations were requested to rule out a potential systemic disorder, and the patient was started on supportive care with regular observation and reassessment while awaiting results. The requested investigations included basic blood tests (Table 1), imaging with X-rays (Figures 1,2), renal ultrasound, and magnetic resonance imaging (MRI).
Table 1
| Laboratory parameter | Patient values | Reference range |
|---|---|---|
| Hemoglobin, g/dL | 8.00 | 13.2–16.6 |
| Red blood cell count, ×1012/L | 2.80 | 4.25–5.65 |
| Hematocrit, % | 24.50 | 38.3–48.6 |
| Platelets, ×109/L | 119.0 | 150.0–400.0 |
| Monocytes, % | 11.6 | 1.7–9.3 |
| Lymphocytes, % | 41 | 20–35 |
| Eosinophils, % | 5.30 | 1.0–4.0 |
| Immature granulocytes, % | 6.2 | ≤3 |
| Nucleated red blood cells, % | 2 | ≤0 |
| Reticulocyte absolute count, ×109/L | 15.40 | 50–100 |
| Width of erythrocyte coefficient, % | 14.9 | 11.8–14.5 |
| Basophils absolute count, ×109/L | 0.01 | 0.031–0.48 |
| C-reactive protein, mg/L | 8 | ≤9 |
| Erythrocyte sedimentation rate, mm/h | 140 | ≤20 |
| Urea, mmol/L | 18.5 | 3.2–8.2 |
| Creatinine, µmol/L | 558 | 65–104 |
| Calcium, mmol/L | 3.34 | 2.28–2.62 |
| Inorganic phosphate, mmol/L | 2.2 | 0.75–1.65 |
| Magnesium, mmol/L | 1.06 | 0.66–1.07 |
| Prothrombin time, s | 12.00 | 10.7–13.9 |
| INR | 1.06 | 0.61–1.17 |
| Activated partial thromboplastin time, s | 18.60 | 25–43 |
| APTT ratio | 0.66 | 0.9–1.4 |
| Total protein, g/L | 91 | 57–82 |
| Globulin, g/L | 54 | 15–30 |
| Total bilirubin, µmol/L | 4 | 5–21 |
| Peripheral blood smear | Red blood cells show rouleaux formation | |
All other laboratory parameters not mentioned were unremarkable. APTT, activated partial thromboplastin time; INR, international normalized ratio.
A renal ultrasound revealed no abnormal findings or obstruction. MRI spine, however, revealed multilevel compression fractures involving T6, T9, L1, L3, and L5 vertebrae with anterior wedging.
The patient was admitted to the hematology department to rule out suspected MM. Moreover, the nephrology department was consulted for renal impairment, and they recommended IV hydration as much as his cardiac status allowed, with regular monitoring of calcium levels, vasculitis screening, and uric acid levels. In case of no improvement of the hypercalcemia, renal replacement therapy was suggested.
The oncology department reviewed the case. Protein electrophoresis and a bone-marrow biopsy showed a high percentage of plasma cells with kappa monoclonality, strongly suggesting a plasma-cell disorder. Immunophenotyping confirmed an elevated CD38 (95.5%), CD56 (62.6%), and cytoplasmic kappa chains, alongside reduced CD19 (2.6%) and cytoplasmic lambda chains, with negative CD20 and CD45 (Table 2). According to current oncology practice guidelines, these findings are consistent with MM.
Table 2
| Antigen marker | Percentage of cells expressing the antigen |
|---|---|
| CD117 | 2.5% |
| CD138 | 0.2% |
| CD19 | 2.6% |
| CD20 | Negative |
| CD38 | 95.5% |
| CD45 | Negative |
| CD56 | 62.6% |
| Cytoplasmic kappa chains | 98.6% |
| Cytoplasmic lambda chains | 2.4% |
The orthopedic surgery department was consulted for the multiple compression fractures on the MRI. The orthopedic team recommended a conservative management plan, including analgesia, physiotherapy, and thoracolumbar support. Should this approach fail to relieve the patient’s pain, vertebroplasty was advised as a subsequent surgical intervention.
After correcting the patient’s hypercalcemia and anemia, the patient was referred to the National Oncology Center to continue his treatment; however, his prognosis could not be determined, and the treatment could not be followed up as he declined care and returned to his home country to continue further treatment.
All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made. The authors strived to the best of their abilities to maintain anonymity of the patient’s details, thereby preventing any possible identification.
Discussion
Key findings
This report describes a middle-aged male who presented with sciatica as the first clinical manifestation of MM, an atypical and rarely documented presentation. While vertebral involvement occurs in approximately 60% of MM cases, radicular pain secondary to compression fractures is seldom the initial complaint (1,2,6). At presentation, the patient exhibited multiple compression fractures, anemia, renal dysfunction, hypercalcemia, and elevated inflammatory markers, while also fulfilling the diagnostic criteria for MM (11-16). This case reinforces that even in younger, non-osteoporotic patients, MM should be considered when sciatica persists without an identifiable musculoskeletal or traumatic cause.
Strengths and limitations
A key strength of this case lies in its comprehensive multidisciplinary assessment combining hematologic, orthopedic, radiologic, and nephrological expertise, which facilitated a timely and accurate diagnosis. Additionally, the detailed immunophenotyping profile (elevated CD38, CD56, and cytoplasmic kappa expression) provides valuable diagnostic and therapeutic insight, correlating with known MM immunoprofiles (17).
However, the main limitation is the incomplete follow-up due to the patient’s transfer abroad, precluding evaluation of treatment response and long-term outcomes. Furthermore, as a single-patient report, the findings cannot be generalized but instead serve to heighten diagnostic awareness for similar atypical presentations.
Comparison with similar research
Few prior reports have documented MM presenting with sciatica as the initial complaint. Southerst et al. described a case of MM initially misdiagnosed as sacroiliac joint pain (7), while Pisklakova et al. and Chakraborti et al. reported cauda equina syndrome and spinal cord compression as presenting features of MM (8,9). In most cases, sciatica was secondary to extramedullary plasmacytomas or localized vertebral collapse rather than diffuse marrow infiltration.
Compared with these reports, the current case demonstrates multilevel vertebral compression fractures rather than isolated lesions, broadening the clinical spectrum of MM-related radiculopathy. The management approach revolving around initial conservative therapy followed by the recommendation of vertebroplasty is consistent with existing literature showing that vertebroplasty provides rapid pain relief, improved mobility, and reduced analgesic dependence in MM patients (6,18,19).
Explanations of findings
The unusual presentation of sciatica can be explained by the anatomical proximity of the lumbosacral nerve roots to collapsed vertebral bodies. Progressive osteolysis and micro-fractures from malignant plasma cell infiltration likely caused foraminal narrowing and nerve irritation, resulting in radicular pain rather than localized back pain.
Additionally, the patient’s relatively young age and absence of osteoporosis may have delayed suspicion for malignant etiology. The constellation of laboratory findings (anemia, renal impairment, and hypercalcemia) reflects the systemic nature of MM-related organ dysfunction due to bone resorption, paraprotein nephropathy, and marrow infiltration (1,11).
The response to conservative management, along with the plan for vertebroplasty, aligns with evidence supporting minimally invasive stabilization to prevent progressive collapse, improve pain control, and enhance quality of life (18,19).
Implications and actions needed
Clinicians should maintain a high index of suspicion for MM in patients presenting with chronic or atypical sciatica, especially when imaging reveals vertebral deformities or lytic changes. Early multidisciplinary assessment involving hematology, radiology, and orthopedics is critical for timely diagnosis.
From a systems perspective, emergency physicians and primary care providers should consider basic laboratory screening (complete blood count, calcium, renal profile, and ESR) in patients with unexplained or treatment-resistant radicular pain. Furthermore, vertebroplasty should be considered early in MM patients with painful vertebral compression fractures. (6,18,19).
Future research should aim to establish clearer diagnostic algorithms and prospective data on the outcomes of early interventional management in atypical MM presentations.
Conclusions
As seen in this case, the management of MM requires a comprehensive, multidisciplinary approach in both diagnosis and management. This includes collaboration among hematologists, oncologists, radiologists, nephrologists, pathologists, orthopedic surgeons, emergency physicians, intensivists, physiotherapists, nurses, and clinical pharmacists. We emphasize the importance of maintaining a high index of suspicion for malignant vertebral fractures, particularly in non-osteoporotic or younger patients without a history of trauma. Early recognition of such non-classical presentations allows for timely diagnostic workup and initiation of therapy, which are crucial for improving prognosis and preventing irreversible complications such as pathological fractures and renal failure.
Given the high prevalence of sciatica, it is perhaps unsurprising that the diagnosis of MM is often overlooked. For patients with spinal involvement, vertebroplasty should be considered when appropriate, as both interventions have demonstrated superior efficacy compared to conservative management in relieving pain and improving quality of life. While radiotherapy, chemotherapy, and surgical options are widely accepted treatments of MM, a significant gap remains in the literature regarding the optimal first-line approach, excluding autologous stem cell transplantation.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-292/rc
Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2025-292/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2025-292/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent for publication of this case report and accompanying images was not obtained from the patient or the relatives after all possible attempts were made. The authors strived to the best of their abilities to maintain anonymity of the patient’s details, thereby preventing any possible identification.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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Cite this article as: Juma AM, Shamtoot Q, Juma MM, Flood J. Sciatica as an atypical initial presentation of multiple myeloma: a case report. AME Case Rep 2026;10:102.
