经皮椎体成形术与开放性手术治疗脊柱转移瘤

【摘要】 目的：探讨经皮椎体成形术（PVP）与开放手术治疗脊柱转移瘤的手术适应证、临床疗效、并发症及外科治疗方式的选择。方法：2004年4月～2011年4月行手术治疗并获得随访的脊柱转移瘤患者共177例，根据手术方法不同分为两组，对原发瘤切除后的孤立转移者，或肿瘤进入椎管压迫脊髓、神经根者，以及脊柱严重不稳者行开放性手术治疗，共87例；对无明显脊髓或神经根受压者，不适宜开放手术者行经皮椎体成形术治疗，共90例。采用VAS评分、ECOG评分、Frankel分级对两组患者的疼痛、功能状况和脊髓功能进行评价；使用Kaplan-Meier法评估两组患者生存率。结果：PVP组共治疗242个椎体，基本无出血，中位手术时间70min；术后2d时VAS评分即有显著降低，并持续至术后1、3、6个月；ECOG评分在术后1周和3个月时均有显著降低；除了无症状的骨水泥渗漏（91/242）外，未发生神经损伤或肺栓塞等严重并发症；中位生存时间为16个月。开放手术组中位手术时间240min，中位出血量1600ml；术后1个月时VAS评分显著降低，并持续至术后3、6个月；ECOG评分在术后1个月和3个月均有显著降低；术前47例有脊髓功能障碍患者中有39例术后Frankel分级得到提高（83%）；29%运动功能完全丧失患者（4/14）和60%运动功能不完全丧失患者（20/33）的神经功能完全恢复；术后17例出现并发症（19.5%），并发症发生率高，围手术期死亡3例（3.4%）；中位生存时间为11个月。结论：经皮椎体成形术对于椎体转移瘤所导致的疼痛和轻中度不稳定是一种安全有效的微创治疗，应作为一线的姑息治疗方法；开放手术应限于原发瘤切除后的孤立转移有硬膜压迫或严重脊柱不稳定的患者。

Percutaneous vertebroplasty vs open surgery for spinal metastasis

Objectives: To investigate the surgical indications,outcomes and complications of percutaneous vertebroplasty(PVP) vs open surgery for spinal metastasis and to discuss the surgical protocol selection.Methods: 87 patients(including solitary metastasis following primary tumor removal,spine canal encroachment by tumor,and violation to the spine stability) experiencing open surgery and 90 patients(including no remarkable neurological deficit,no suitable for open surgery) undergoing percutaneous vertebroplasty between April 2004 and April 2011 were reviewed retrospectively.VAS score,ECOG score and Frankel scale were used to evaluate the pain and neurofunction between two groups.Kaplan-Meier method was used to determine the survival rate between 2 groups.Results: A total of 242 vertebrae underwent PVP with the median surgical time of 70min,VAS score decreased significantly at 2 days after PVP,which maintained till 6 months later;ECOG score at 1 week and 3 months decreased significantly;91 of 242 vertebrae suffered from asymptomatic bone cement leakage;the median survival time was 16 months.While for open surgery,the median surgical time was 240 minutes with the median blood loss of 1600ml;VSA score at 1 month decreased significantly,which maintained till 6 months;ECOG score at 1 week and 3 months decreased significantly;83% of the cases complicated with neurological deficit had Frankel scale improved;29% cases with complete paraplegia and 60% with incomplete paraplegia had neurofunction recovered completely;complications were noted in 17 cases(19.5%),and peripheral surgical death was noted high(3.4%);the median survival time was 11 months.Conclusions: PVP is indicated for pain and mild-to-moderate instability due to spine metastasis,while open surgery is indicated for neurological deficit and severe instability due to solitary spine metastasis following primary tumor removal.