胸腰椎转移瘤的手术治疗

目的：探讨胸腰椎转移瘤手术治疗的适应证及意义。方法：回顾性分析１９８１年至2001年经手术治疗并获得随访的胸腰椎转移瘤61例，所有病例术前均有顽固性疼痛，其中37例伴有病理骨折，25例伴有脊髓神经损害，Tokuhashi评分6－12分，平均9．5分，61例均手术切除病椎，并采用不同方式重建脊柱稳定性，术后平均随访38个月。结果：61例术后疼痛均明显好转，术前有神经症状的25例中20例有不同程度的恢复，Tokuhashi评分8分以上者47例，术后平均存活22．3个月，小于8分者14例，平均存活5．7个月，3例乳癌转移，2例甲状腺癌转移患者，术后已存活5年以上，结论：胸腰椎转移瘤合并严重疼痛或／和神经功能受损，Tokuhashi评分8分以上者，手术治疗可改善症状，提高生活质量。延长生存期。     

Indications and range of surgery in the treatment of spine metastatic tumours

Background. Spine is the most common place of metastatic tumors in the skeletal system. Due to diagnostic problems and the risk of quickly increasing neurological defects, the treatment of metastatic spine tumors is a significant clinical problem. The goal of surgical treatment is decreasing pain, neurological improvement and achieving full spinal stability.
Material and methods. Material consists of 31 patients with metastases in spine, who underwent spine surgery. Tumors were placed in thoracic spine at 48% patients, at lumbar spine - 42% patients, and at cervical spine in 10% patients; one level was involved in 56% cases, two or more levels - in 44 % cases. Qualification for surgery contained: the type of primary tumor, the amount of metastases to the spine impairment of spinal biomechanics and overall patient's condition of the. Corporectomy with anterior stabilization (intervertebral cage) was performed at 13 patients, and with additional anterior implants at 2 cases. At 8 patients, with destabilization of posterior spinal column, in spite of corporectomy, posterior stabilization was done. Surgery from posterior approach was performed in 3 cases.
Results. After operation, we noted pain relief at 34% of patients, while in 14% of them transient increase of pain occurred. Neurological status worsened after surgery at 1 patient. We achieved proper spine stabilization, without the need of use of external orthoses at 30 patients. At one patients, reoperation with change of implants and the range of stabilization was necessary. The amount of complications correlated with patient's general condition at the time of surgery.
Conclusions. 1. The main condition of success in operative treatment of spinal metastatic tumors is individual patient's qualification for surgery, including the extent of disease and general patient's condition. 2. Good stabilization with use of implants is a necessary element of surgery of spinal metastases from both anterior and posterior approach.     

外科切除与重建治疗脊柱转移肿瘤

目的：探讨脊柱转移瘤患者的手术切除与脊柱稳定性重建的适应证与效果。方法：2003年4月至2008年4月,收治了脊柱转移癌患者32例。肿瘤转移部位：胸椎转移22例,腰椎转移7例,颈椎转移3例。男性13例,女性19例。出现神经系统受损者27例,其中完全瘫痪者7例,不完全瘫痪者20例。全组患者均做了椎体切除、内固定术或后路椎板切除、椎管减压内固定术或前后路联合行360。脊椎切除固定一期重建脊柱稳定性。观察术后局部疼痛缓解,神经功能恢复及脊柱稳定性情况。结果：随访时问为6～60个月,32例患者中,30例术后痛疼得到缓解。27例有神经功能损害的患者中,25例术后麻痹症状改善。3例完全瘫痪的患者中,2例在减压术后ASIA分级提高了1～2个等级。术后影像学提示脊柱序列和椎间高度恢复。术后存活1年以上的患者22例,约占患者总数的69％。结论：外科切除与重建治疗转移癌所致椎体塌陷或不稳定造成严重的神经损害或机械性脊柱痛疼的外科疗效肯定,能够增加脊椎稳定性,提高生存质量。     

伽玛刀对神经根与毗邻血管不同解剖关系的原发性三叉神经痛的治疗疗效分析

目的探讨原发性三叉神经痛患者三叉神经根与毗邻血管的不同解剖关系对伽玛刀治疗疗效的影响。方法回顾性分析2004年1月至2009年1月山西医科大学第二医院伽玛刀中心治疗原发性痛患者82例，依据MR定位影像显示三叉神经根与毗邻血管的不同解剖关系（无接触、可疑接触、明确接触、推移），评估对伽玛刀治疗疗效的影响。结果随访6～18个月，平均随访12．5个月，依据BNI疼痛量表评分Ⅲ级以上70例，总有效率85．4％，三叉神经根与血管无接触组有效率89．7％，可疑接触组有效率86．4％，明确接触78．9％，推移组81．8％，复发8例（9．7％）。结论三叉神经根与毗邻血管的不同解剖关系对伽玛刀治疗疗效差别无统计学意义，推移组复发率较其他组高，远期疗效有待进一步评估。     

原发性三叉神经痛伽玛刀放射外科治疗的有效性评估

目的:评价伽玛刀放射外科治疗原发性三叉神经痛的安全性、有效性和心理状态。方法:2004年8月~2010年9月,98例经药物和其他方法治疗无效的原发性三叉神经痛患者接受伽玛刀放射外科治疗。放射剂量中位值是80 Gy(75~85 Gy)。采用患者自我报告疼痛的控制、生活满意度指数A(1ife satisfaction index A,LSI-A)的变化进行疗效评估。结果:治疗后89例(90.8%)患者获得随访,平均随访期35个月(13~60个月)。本组病例中治愈51例(57.3%);显效19例(21.3%);有效11例(12.4%);无效8例(9%),总有效率为91%;伽玛刀治疗后LSI-A总分平均值(36.25±3.87)高于治疗前(25.67±3.5);其中67例以往未接受过手术治疗患者中62例获得随访,58例有效,总有效率为93.5%。11例患者感觉患侧面部麻胀感,1例(二次治疗者)张口轻度受限。结论:伽玛刀放射外科治疗三叉神经痛显著缓解疼痛,提高生存质量。     

Current trends in mini-invasive management of spine metastases

The spine is a frequent localization of primary tumours or metastasis involving posterior arch, pedicles and vertebra body, and often causing unsustainable pain. The management of spinal metastasis remains complex, including medical therapy (corticosteroids, chemotherapy), radiotherapy and surgical treatment, or the recent percutaneous mini-invasive approach. The target of all these treatments is to improve the quality of life of patients affected by this type of lesion. Diagnosis of spinal metastasis and then its treatment should be based on the combination of different elements: clinical evaluation, CT, MRI and nuclear medicine patterns, considering the age of the patient, known primary tumour, location of the lesions, single/multiple lesions, pattern of morphology (border, matrix, expansile character, soft tissue extension), density or signal intensity, oncologic instability and expectancy of life. The percutaneous mini-invasive approach for patients affected by secondary lesions involving the spine has as treatment goal of: (1) pain relief improving the quality of life; (2) stability treatment re-establishing the spinal biomechanics, alterated by bone destruction or deformity, preventing pathological fracture; and (3) an anti-neoplastic effect. The aim of this paper is to provide a comprehensive diagnostic and percutaneous approach to the bone metastatic spine lesions, identifying which metamer should be treated to improve patient quality of life, showing the importance of a multi-disciplinary approach to this problem.     

肺癌骨转移放射止痛治疗的临床分析

目的分析36例肺癌骨转移放射治疗止痛效果。方法采用6MV或15MV-X线照射肺癌骨转移患者36例共计50处病灶,常规分割照射32处病灶,照射剂量：21．6-60Gy／12-30次,共3-6周,非常规分割照射18处,照射剂量：29．7-45Gy／3-15次,共1-3周。结果全组50处病灶放疗止痛总有效率92．00％,且与照射总剂量、时间-剂量分割方式、照射部位、原发灶是否行局部治疗、转移灶是单发或多发无关系。起效时间与剂量分割方式有关,非常规分割照射起效快（P-0．0125）。全组有7例患者,计10处病灶在放射期间有疼痛加重．但其发生率与照射方式无关。结论放射治疗肺癌骨转移止痛效果确切,可提高患者生存质量,已成为肺癌骨转移止痛治疗的主要方法。     

Vertebroplasty with methacrylate bone cement and radiotherapy in the treatment of spinal metastases with epidural spinal cord compression. Preliminary report

Background. The choice of treatment method for metastases to the spine remains an unresolved and controversial question. The major complication in disseminated neoplastic disease compression of the spine and nervous elements. Vertebroplasty performed jointly with palliative radiotherapy has been proposed as a procedure to treat metastases complicated by cancer infiltrations in the vicinity of the spine. Material and methods. We examined 21 patients treated since May 2004. Vertebroplasty was performed by surgery using acrylic cement, followed by palliative radiotherapy. Results. Outcome was assessed by clinical examination, neurological evaluation, and other methods, such as X-ray, CT scan, and MRI. All patients showed prompt relief of pain and substantial improvement in mobility. No complications or side effects were observed in connection with the joint palliative treatment. Conclusions. Vertebroplasty is an effective method and works to help stabilize spinal fractures. Satisfactory results were obtained using palliative treatment. The use of acrylic cement made it possible to perform radiotherapy safely with an optimum margin of healthy tissues, which enhances treatment. These initial results point to the need for further clinical collaboration between neurosurgeon and radiotherapist.     

Evaluation of efectiveness of palliative radiotherapy alone or combined with surgery in patients with bone metastases

Material and methods. The retrospective analysis results of palliative radiotherapy alone or combined with surgery of 200 patients with bone metastases are presented. All patient were irradiatated, 47 of them were operated before or after radiotherapy. General performance status, pain relief, movement efficiency, analgetic drugs and bisphosphonates administration, disease progress and bone reossification were assesed 1, 2, 3, 6, 12 months after the treatment and durning the last examination.
Results. The complete or partial pain relief were observed in 47% of patients 1 month, 56% two months 41% in 3, 38% 6 months after the treatment. 26% reported pain relief 1 year after irradiation and 33% at the last visit
The Kaplan Maier survival analysis shows ststistically significant longer survival for patient treated by combined treatment, women, patients with multiple bone metastases and patients with metastases located in long bones and patients without symptoms of spine compression. Spearman analysis reveals correlation beetween performance status and follow up. There are no correlations between radiation dose, bisphosphonates administration and pain relief, pathology of tumor and follow up.
Conclusions. The obtained results suggests that radiotherapy is effective method of analgetic treatment in bone metastases and that radiotherapy associated with surgery improves survival.     

伽玛刀治疗原发性三叉神经痛疗效观察

目的 探讨伽玛刀治疗原发性三又神经痛的疗效.方法 2003年1月至2008年3月,我院应用伽玛刀治疗原发性三又神经痛120例;治疗靶点为三叉神经根,用4 mm准直器,靶点中心计量为80～90 Gy.疗效评估采用患者自我报告疼痛的控制程度及药物用量的变化.结果 所有患者进行了随访,平均随访期(20.0±4.5)个月.本组病例中治愈69例(57.5%);显效34例(28.3%)、有效12例(10.0%)、无效5例(4.2%);总有效率为95.8%.5例患者疼痛复发后行其他治疗.83例患者(69.2%)曾出现一过性、局限性的面部麻木.14例患者(11.7%)在疼痛缓解后留下持续性的面部麻木;部分患者还伴有味觉减退、口嚼无力等主诉.结论 伽玛刀治疗原发性三又神经痛能够显著缓解疼痛、提高生活质量,不良反应发生率较低:是一种较为理想的治疗方法.     

Percutaneous vertebroplasty with methyl methacrylate bone cement in the treatment of spinal angiomas and neoplasms

Background. The authors report their own experience with percutaneous vertebroplasty. Percutaneous vertebroplasty is a technique which allows to inject acrylic surgical cement into the vertebral body. This is minimally invasive method indicated in treatment of certain spinal lesions affecting the vertebral bodies, as osteoporotic fractures, angiomas and focal neoplasms.
Material and methods. Since October 1999 the authors treated 7 patients with angiomas of the vertebral bodies and 11 patients with spinal neoplasms. Cement injections were realized under local anesthesia.
Results. In group of 7 cases with spinal metastases 3 patients declared important pain relief. All 7 patients with spinal angiomas declared no pain in follow-up.
Conclusions. Percutaneous vertebroplasty is well-tolerated by patients. Filling by cement is efficace in treatment of vertebral angiomas. Filling of spinal neoplasmatic lesions result in palliative pain relief.     

CyberKnife: review of first 1,000 cases at a dedicated therapy center

Purpose  The development of the CyberKnife technology, a combination of image guidance and industrial robotics, led to a paradigm shift in radiosurgery. Materials and methods  The CyberKnife Robotic Radiosurgery System consists of a 6-MV compact LINAC mounted on a computer-controlled robotic manipulator capable of 6 degrees of freedom, with a dedicated image-guidance system which acquires X-ray images during treatment. Apart from standard neurosurgical indications (i.e., acoustic neurinomas, meningiomas, brain metastases, etc.) radiosurgical applications are currently evolving to include extracranial indications such as tumors of the spine, pancreas, lung, and liver. We reviewed the indications and outcomes in the first 1,000 patients treated in the CyberKnife Center Munich. Single-dose treatment was chosen because published clinical studies have demonstrated high efficacy and low morbidity for intracranial and spinal tumors. A recent development in radiosurgery is breathing-triggered real-time correction for respiratory motion of tumors, which makes it possible to apply radiosurgical doses to moving targets. CyberKnife treatment is designed to be delivered on an outpatient basis, mostly consisting of a single treatment session lasting between 60 and 90 min. High quality imaging is of utmost importance for successful radiosurgical applications. For example, high-field MRI, multislice CT’s, PET and PET-CT imaging data must be integrated in the planning phase for optimal target definition. Results  A total of 750 patients with brain tumors were treated at the CyberKnife Center Munich in cooperation with the Department of Neurosurgery of the University Munich. A total of 285 patients with brain metastases received 339 treatments for 780 brain metastases. The first 55 spinal tumor patients were analyzed and have a mean follow-up of 14 months (out of 200 spinal tumor patients treated at our facility). Efficacy was high and complications minimal for all patient groups. Conclusion  CyberKnife radiosurgery technology may be used as a primary treatment modality or in multidisciplinary cancer therapy. Patient selection, high quality diagnostic imaging and consideration of alternative modes of therapy are key issues in optimizing the benefits of CyberKnife treatment.     

Stereotactic radiosurgery for the treatment of trigeminal neuralgia.

Stereotactic radiosurgery is an increasingly used and the least invasive surgical option for patients with medically refractory trigeminal neuralgia (TN). The authors began use of this technique at our center in 1992 and have evaluated outcomes serially. Independently acquired data from 220 patients with idiopathic TN that had Gamma Knife radiosurgery was reviewed. The median radiosurgery dose was 80 Gy with a range of 60 to 90 Gy. Most patients had features of typical TN, although 16 (7.3%) described additional atypical features. One hundred thirty-five patients (61.4%) had prior surgery. Patients were followed to a maximum of 6.5 years (median, 2 years). Complete or partial pain relief was achieved in 85.6% of patients at 1 year. Complete pain relief was achieved in 64.9 % of patients at 6 months, 70.3% at 1 year, and 75.4% patients at 33 months. Patients with an atypical pain component had a lower rate of achieving pain relief ( p = 0.025). Due to recurrences, 55.8% of patients had complete or partial pain relief at 5 years. The absence of preoperative sensory disturbance or prior surgery correlated with an increased proportion of patients in complete or partial pain relief over time. Ten percent of patients developed new or increased subjective facial paresthesia or facial numbness. Radiosurgery for idiopathic TN was safe and effective, and provided benefit to a patient population with a high frequency of prior surgical intervention. It is an important addition to the surgical armamentarium for TN.     

Treatment procedure in spinal metastases: the orthopedic dimension

Background. The authors have presented the results of the medical treatment of patients with metastatic disease of the spine. The aim of this treatment was to improve the patients quality of life through spinal stabilisation, maintaining neurological functions and the maximum pain relief.
Material and methods. Surgical indications included progressive, neurological deficit, fracture of vertebra, spine instability and histologic diagnosis. The patients underwent anterior, posterior or combined decompression and stabilisation procedures with the use of implants. Neurological examination of the patients has been carried out by means of Frankel grade whereas the tool for measurement of vertebra destruction was Harrington classification.
The results and the treatment for spinal metastatic tumors of the 86 patients were treated from 1997 to 2002.
There were 55 men and 33 women with a median age of 56 years. The mean survival time after surgery was 7,5 months.
Results. The improvement in neurological state of 28 in 59 patients was recorded. 11 patients have died of health conditions during the medical treatment as a consequences of the metastases.
Conclusions. The full decompression and stabilisation of the spine should be carried out in order to avoid the consequences and enable the patients to continue oncological treatment. The early diagnostic and good health conditions have been stressed. The can help in patient's qualification to surgical treatment, improve the general results of the treatment while giving the full satisfaction to the surgeon and the patient, prolonging the patient's life and improving his comfort of life by pain restriction and the protection of neurological consequences.     

99mTc-亚甲基二膦酸盐骨显像评价乳腺癌骨转移的特征

目的 探讨乳腺癌骨转移99mTc-亚甲基二膦酸盐（MDP）全身骨显像及SPECT/CT融合显像的特征。 方法 收集我院2016年1月~2017年5月经病理组织学及免疫组化确诊的乳腺癌资料。初诊时即发现骨转移的患者46例,所有患者均在治疗前行99mTc-MDP全身骨显像,疑骨转移或不明原因骨痛部位行SPECT/CT融合显像。分析三阴乳腺癌（TNB）与非TNBC骨转移病灶分布情况,总结乳腺癌骨转移99mTc-MDP全身骨显像及SPECT/CT融合显像的特点。 结果 共检出46例患者204处病变,脊柱62处（30.39%）,是转移最常见部位,其次肋骨57处（27.94%）、胸部骨31处（15.20%）、骨盆骨28处（13.73%）、颅面骨15处（7.35%）、四肢骨11处（5.39%）。三阴乳腺癌与非三阴乳腺癌、TNBC与非TNBC骨转移在脊柱、肋骨、胸部骨、骨盆骨、颅面骨及四肢骨的病灶分布比例差异无统计学意义（χ2=0.591,P=0.988）。三阴乳腺癌骨转移占整个乳腺癌骨转移的28.26%（13/46）。13例TNBC骨转移共51处病灶,放射性浓聚占90.20%（46/51）, 混合型病灶占7.84%（4/51）,放射性稀疏病变1.96%（1/51）, 且主要为多发骨转移病变, 占84.62%（11/13）。 结论 99mTc-MDP全身骨显像及SPECT/CT融合显像对乳腺癌的早期诊断有重要价值,TNBC骨转移好发与脊柱、肋骨、胸骨,以多发性、放射性浓聚病变为主。       

Delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation: Case report with histopathologic-MRI correlation

Stereotactic radiosurgery and percutaneous radiofrequency ablation are emerging therapies for pain palliation and local control of spinal metastases. However, the post-treatment imaging findings are not well characterized and the risk of long-term complications is unknown. We present the case of a 46-year-old woman with delayed vertebral body collapse after stereotactic radiosurgery and radiofrequency ablation of a painful lumbar metastasis. Histopathologic-MRI correlation confirmed osteonecrosis as the underlying etiology and demonstrated that treatment-induced vascular fibrosis and tumor progression can have identical imaging appearances.     

应用经皮椎体成形术治疗累及硬膜外间隙的疼痛性椎体转移瘤

目的 评估伴随或不伴相关神经压迫症状的硬膜外间隙受累椎体转移瘤患者行经皮椎体成形术的可行性、安全性以及疗效.方法 回顾性分析行经皮椎体成形术的硬膜外受累椎体转移瘤患者36例,每例各有一个椎体病变破坏椎体后缘或肿瘤侵犯硬膜外,10例伴有脊髓或马尾神经受压的症状.本组治疗36例患者共59个患椎.通过观察术后是否发生不良事件进行安全性评价;观察患者手术前后的疼痛程度变化进行镇痛疗效评估.有效疼痛缓解的定义为术后视觉模拟评分(visual analogue scale,VAS)较术前疼痛评分改善至少50%.随访评估分别在手术后1 d,1周,1、3和6个月进行.结果 患者有效疼痛缓解率术后1 d及1周为97.2%(35/36),术后1个月为88.2%(30/34),术后3个月为84.4%(27/32),术后6个月为75.O%(21/28).骨水泥渗漏发生率为59.3%(35/59).所有患者无临床并发症发生.结论 经皮椎体成形术对于累及硬膜外间隙的疼痛性椎体转移瘤是一种安全有效的微创治疗方式.无论有或无相关神经压迫症状,其不应被视为经皮椎体成形术的禁忌证.     

Percutaneous Sacroplasty and Sacroiliac Joint Cementation under Fluoroscopic Guidance for Lower Back Pain Related to Sacral Metastatic Tumors with Sacroiliac Joint Invasion

Abstract: Cancer patients with bone metastases are at risk of a variety of skeletal events, including vertebral compression and pathologic fractures. Approximately 30% to 40% of patients with advanced lung cancer will develop bone metastases in the course of their disease, resulting in a significant negative impact on both morbidity and survival. Skeletal complications of bone metastases include pain, pathologic fractures, spinal cord compression, and hypercalcemia. The spine is the most frequent site of skeletal metastases. We present a 48‐year‐old female with intractable and incapacitating low back pain because of metastatic bone tumor in the left lateral side of S1 and S2 with left sacroiliac invasion. Imaging identified a metastatic invasion of the sacrum. Percutaneous sacroplasty, a safe and effective procedure for sacral‐insufficient fractures, was performed under fluoroscopy guidance. However, the expected pain relief was not achieved. At 1 month, the patient remained invalided by severe back pain, which was localized to the left sacroiliac joint. In a second procedure, the sacroiliac joint was cemented. Pain relief was complete, immediate, and sustained until the patient's death related to the underlying oncologic disease. No complications were observed. Few reports exist about the treatment of sacral metastatic tumors with percutaneous sacroplasty. Further, no previous reports about sacroiliac joint cementation for joint stabilization have been found. In the present case, sacroiliac joint cementation successfully resolved residual pain that remained despite percutaneous sacroplasty treatment of the pathologic sacral fracture.     

Spinal cord stimulation in the treatment of failed back surgery syndrome

A significant number of patients undergoing lumbar spine surgery do not obtain pain relief. Such patients with chronic low back or lower extremity pain may be difficult to treat. A frequent component of therapy is the use of spinal cord stimulation to help control pain. With careful patient selection, many patients can achieve reasonable levels of pain relief. We review recent clinical reports, including prospective and randomized studies, that demonstrate up to three quarters of patients implanted with a spinal cord stimulator for the treatment of failed back surgery syndrome may benefit from its use. This technology must not be indiscriminately applied. Careful patient selection and a period of trial stimulation are vital to the successful use of spinal cord stimulation as treatment for chronic pain.     

Repeat trigeminal nerve radiosurgery for refractory cluster headache fails to provide long-term pain relief

OBJECTIVE/BACKGROUND: Medically refractory cluster headache (MRCH) is a debilitating condition that has proven resistant to many modalities. Previous reports have indicated that radiosurgery for MRCH provides little long-term pain relief, with moderate/significant morbidity. However, there have been no reports of repeated radiosurgery in this patient population. We present our findings from the first reports of repeat radiosurgery for MRCH. METHODS: Two patients with MRCH underwent repeat gamma knife radiosurgery at our institution. Each fulfilled clinical criteria for treatment, including complete resistance to pharmacotherapy, pain primarily localized to the ophthalmic division of the trigeminal nerve, and psychological stability. Both patients previously received gamma knife radiosurgery (75 Gy) for MRCH with no morbidity, but no long-term improvement of pain relief (Patient 1 = 5 months, Patient 2 = 10 months) after treatment. For repeat radiosurgery, each patient received 75 Gy to the 100% isodose line delivered to the root entry zone of the trigeminal nerve, and was evaluated postretreatment. Pain relief was defined as: excellent (free of MRCH with minimal/no medications), good (50% reduction of MRCH severity/frequency with medications), fair (25% reduction), or poor (less than 25% reduction). RESULTS: Following repeat radiosurgery, long-term pain relief was poor in both patients. Neither patient sustained any immediate morbidity following radiosurgery. Patient 2 experienced right facial numbness 4 months postretreatment, while Patient 1 experienced no morbidity. CONCLUSION: Repeat radiosurgery of the trigeminal nerve fails to provide long-term pain relief for MRCH. Given the reported failures of initial and repeat radiosurgery for MRCH, trigeminal nerve radiosurgery should not be offered for MRCH.