脊柱转移性肿瘤的手术疗效及生存危险因素分析
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摘要
目的探究脊柱转移肿瘤手术对改善疼痛及神经功能的临床疗效,并对可能影响脊柱转移瘤病人生存的危险因素进行分析。方法选取我院2010年6月至2018年12月期间接受脊柱外科手术(后路脊柱肿瘤刮除椎弓根螺钉减压内固定术、椎体成形术、射频消融术)的45例脊柱转移性肿瘤病人进行回顾性分析。术前应用Tomita评分、改良Tokuhashi评分对病人进行术前评估。术后应用疼痛视觉模拟量表(visual analogue scale, VAS)及Frankel分级对病人疼痛的改善及神经功能恢复情况进行评估。对转移性脊柱肿瘤病人的生存时间进行单因素分析,纳入的变量包括性别、BMI、手术年龄是否大于60岁、原发肿瘤的恶性程度、原发肿瘤手术治疗、肿瘤的位置、转移瘤的数目、是否存在病理性骨折、术前Frankel分级、术中出血量、术前ECOG评分。根据单因素分析的结果进一步进行Cox生存分析。结果 45例均接受了脊柱转移瘤手术并获得随访,随访时间为2～80个月,中位随访时间为9个月。与术前相比,术后的生活质量有明显的改善,疼痛VAS评分明显下降(P<0.001),神经功能Frankel等级明显改善(P<0.001)。转移性脊柱肿瘤病人术后1、2年生存率分别为(54±8)%、(46±10)%,而是否存在病理性骨折(HR=2.5,P=0.043)是影响此研究预后的独立危险因素。结论外科手术治疗可以明显改善病人的疼痛水平、生活质量与神经功能状态,而术前是否存在病理性骨折是影响转移性脊柱肿瘤病人生存预后的主要因素。
Objective To discuss the surgical outcomes on pain and neural function of spinal metastatic tumor and the potential prognosis factors. Methods From June 2010 to December 2018, 45 patients with spinal metastatic tumors who underwent spinal surgery(posterior spinal tumor resection and decompression internal fixation, percutaneous vertebroplasty, radiofrequency ablation) were retrospectively analyzed. Tomita score and modified Tokuhashi score were used to evaluate the patients before operation.Visual analogue scale(VAS) and Frankel scale were used to evaluate the improvement of pain and the recovery of neurological function. Univariate analysis of survival time of patients with metastatic spinal tumors included gender, BMI, age over 60, malignant degree of primary tumors, surgical treatment of primary tumors, location of tumors, number of metastatic tumors, pathological fracture, preoperative Frankel classification, intraoperative bleeding, preoperative ECOG score. Cox survival analysis was further carried out according to the results of univariate analysis. Results Forty-five patients underwent the surgery and follow-up. The follow-up period ranged from 2 to 80 months, with an average of 9 months. The quality of life had been improved after the spinal surgery. The VAS score and Frankel score had been improved since the surgery(both P<0.001). The 1-and 2-year survival rate for those patient was(54±8)% and(46±10)% respectively. For patients with metastatic spinal tumor, survival analysis of metastatic spinal tumor demonstrated that pathologic fracture was significant prognostic factor(HR=2.5, P=0.043). Conclusion Surgical operation can significantly improve the pain symptom, quality of life and neurological function. Whether combination of pathologic fracture is a major significant prognostic factor.
Objective To discuss the surgical outcomes on pain and neural function of spinal metastatic tumor and the potential prognosis factors. Methods From June 2010 to December 2018, 45 patients with spinal metastatic tumors who underwent spinal surgery(posterior spinal tumor resection and decompression internal fixation, percutaneous vertebroplasty, radiofrequency ablation) were retrospectively analyzed. Tomita score and modified Tokuhashi score were used to evaluate the patients before operation.Visual analogue scale(VAS) and Frankel scale were used to evaluate the improvement of pain and the recovery of neurological function. Univariate analysis of survival time of patients with metastatic spinal tumors included gender, BMI, age over 60, malignant degree of primary tumors, surgical treatment of primary tumors, location of tumors, number of metastatic tumors, pathological fracture, preoperative Frankel classification, intraoperative bleeding, preoperative ECOG score. Cox survival analysis was further carried out according to the results of univariate analysis. Results Forty-five patients underwent the surgery and follow-up. The follow-up period ranged from 2 to 80 months, with an average of 9 months. The quality of life had been improved after the spinal surgery. The VAS score and Frankel score had been improved since the surgery(both P<0.001). The 1-and 2-year survival rate for those patient was(54±8)% and(46±10)% respectively. For patients with metastatic spinal tumor, survival analysis of metastatic spinal tumor demonstrated that pathologic fracture was significant prognostic factor(HR=2.5, P=0.043). Conclusion Surgical operation can significantly improve the pain symptom, quality of life and neurological function. Whether combination of pathologic fracture is a major significant prognostic factor.
引文
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[24]Llovet JM,Ricci S,Mazzaferro V.Sorafenib in advanced hepatocellular carcinoma[J].N Engl J Med,2008,359(4):378-390.
[25]Topalian SL,Hodi FS,Brahmer JR,et al.Safety,activity,and immune correlates of anti-PD-1 antibody in cancer[J].N Engl JMed,2012,366(26):2443-2454.
[26]Koike Y,Takizawa K,Ogawa Y,et al.Transcatheter Arterial Chemoembolization(TACE)or embolization(TAE)for symptomatic bone metastases as a palliative treatment[J].Cardiovasc Intervent Radiol,2011,34(4):793-801.
[27]Klimo P Jr,Thompson CJ,Kestle JR,et al.A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease[J].Neuro Oncol,2005,7(1):64-76.
[28]Choi D,Fox Z,Albert T,et al.Rapid improvements in pain and quality of life are sustained after surgery for spinal metastases in a large prospective cohort[J].Br J Neurosurg,2016,30(3):337-344.
[29]Quan GM,Vital JM,Aurouer N,et al.Surgery improves pain,function and quality of life in patients with spinal metastases:a prospective study on 118 patients[J].Eur Spine J,2011,20(11):1970-1978.
[30]Kataoka M,Kunisada T,Tanaka M,et al.Statistical analysis of prognostic factors for survival in patients with spinal metastasis[J].Acta Med Okayama,2012,66(3):213-219.
[2]Sutcliffe P,Connock M,Shyangdan D,et al.A systematic review of evidence on malignant spinal metastases:natural history and technologies for identifying patients at high risk of vertebral fracture and spinal cord compression[J].Health Technol Assess,2013,17(42):1-274.
[3]Ortiz Gómez JA.The incidence of vertebral body metastases[J].Int Orthop,1995,19(5):309-311.
[4]Aebi M.Spinal metastasis in the elderly[J].Eur Spine J,2003,12(Suppl 2):S202-S213.
[5]蒋伟刚,刘耀升,刘蜀彬.脊柱转移瘤的外科治疗进展[J].中国矫形外科杂志,2015,23(1):55-59.
[6]Stieler F,Wolff D,Bauer L,et al.Reirradiation of spinal column metastases:comparison of several treatment techniques and dosimetric validation for the use of VMAT[J].Strahlenther Onkol,2011,187(7):406-415.
[7]Bartels RH,van der Linden YM,van der Graaf WT.Spinal extradural metastasis:review of current treatment options[J].CA Cancer J Clin,2008,58(4):245-259.
[8]Lee BH,Park JO,Kim HS,et al.Perioperative complication and surgical outcome in patients with spine metastases:retrospective200-case series in a single institute[J].Clin Neurol Neurosurg,2014,122:80-86.
[9]Joaquim AF,Powers A,Laufer I,et al.An update in the management of spinal metastases[J].Arq Neuropsiquiatr,2015,73(9):795-802.
[10]Tomita K,Kawahara N,Kobayashi T,et al.Surgical strategy for spinal metastases[J].Spine(Phila Pa 1976),2001,26(3):298-306.
[11]Tokuhashi Y,Matsuzaki H,Oda H,et al.A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis[J].Spine(Phila Pa 1976),2005,30(19):2186-2191.
[12]Tabouret E,Cauvin C,Fuentes S,et al.Reassessment of scoring systems and prognostic factors for metastatic spinal cord compression[J].Spine J,2013,15(5):944-950.
[13]Lee CS,Jung CH.Metastatic spinal tumor[J].Asian Spine J,2012,6(1):71-87.
[14]王丰,伦登兴,张浩,等.脊柱转移瘤481例的流行病学分析[J].中国脊柱脊髓杂志,2017,27(9):787-794.
[15]Enneking WF,Dunham WK.Resection and reconstruction for primary neoplasms involving the innominate bone[J].J Bone Joint Surg Am,1978,60(6):731-746.
[16]Boriani S,Weinstein JN,Biagini R.Primary bone tumors of the spine.Terminology and surgical staging[J].Spine(Phila Pa 1976),1997,22(9):1036-1044.
[17]Tokuhashi Y,Matsuzaki H,Toriyama S,et al.Scoring system for the preoperative evaluation of metastatic spine tumor prognosis[J].Spine(Phila Pa 1976),1990,15(11):1110-1113.
[18]Bauer HC,Wedin R.Survival after surgery for spinal and extremity metastases.Prognostication in 241 patients[J].Acta Orthop Scand,1995,66(2):143-146.
[19]Leithner A,Radl R,Gruber G,et al.Predictive value of seven preoperative prognostic scoring systems for spinal metastases[J].Eur Spine J,2008,17(11):1488-1495.
[20]Mok TS,Wu YL,Thongprasert S,et al.Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma[J].N Engl J Med,2009,361(10):947-957.
[21]Thatcher N,Chang A,Parikh P,et al.Gefitinib plus best supportive care in previously treated patients with refractory advanced non-small-cell lung cancer:results from a randomised,placebocontrolled,multicentre study(Iressa Survival Evaluation in Lung Cancer)[J].Lancet,2005,366(9496):1527-1537.
[22]Piccart-Gebhart MJ,Procter M,Leyland-Jones B,et al.Trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer[J].N Engl J Med,2005,353(16):1659-1672.
[23]Beuselinck B,Oudard S,Rixe O,et al.Negative impact of bone metastasis on outcome in clear-cell renal cell carcinoma treated with sunitinib[J].Ann Oncol,2011,22(4):794-800.
[24]Llovet JM,Ricci S,Mazzaferro V.Sorafenib in advanced hepatocellular carcinoma[J].N Engl J Med,2008,359(4):378-390.
[25]Topalian SL,Hodi FS,Brahmer JR,et al.Safety,activity,and immune correlates of anti-PD-1 antibody in cancer[J].N Engl JMed,2012,366(26):2443-2454.
[26]Koike Y,Takizawa K,Ogawa Y,et al.Transcatheter Arterial Chemoembolization(TACE)or embolization(TAE)for symptomatic bone metastases as a palliative treatment[J].Cardiovasc Intervent Radiol,2011,34(4):793-801.
[27]Klimo P Jr,Thompson CJ,Kestle JR,et al.A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease[J].Neuro Oncol,2005,7(1):64-76.
[28]Choi D,Fox Z,Albert T,et al.Rapid improvements in pain and quality of life are sustained after surgery for spinal metastases in a large prospective cohort[J].Br J Neurosurg,2016,30(3):337-344.
[29]Quan GM,Vital JM,Aurouer N,et al.Surgery improves pain,function and quality of life in patients with spinal metastases:a prospective study on 118 patients[J].Eur Spine J,2011,20(11):1970-1978.
[30]Kataoka M,Kunisada T,Tanaka M,et al.Statistical analysis of prognostic factors for survival in patients with spinal metastasis[J].Acta Med Okayama,2012,66(3):213-219.