脊柱多发性骨髓瘤的诊断与治疗———附36例报告

Diagnosis and treatment of spinal multiple myeloma:36 cases report

中文关键词:  多发性骨髓瘤  脊柱  诊断  治疗

英文关键词:Multiple myeloma  Spine  Diagnosis  Treatment

中文摘要:

  【摘要】 目的：探讨脊柱多发性骨髓瘤（multiple myeloma，MM）的诊断与外科治疗方法选择。方法：回顾性分析收治的脊柱MM患者36例的临床资料，平均年龄为55.5岁（34～78岁）。患者均有局部疼痛；伴有神经功能损害25例。26例行CT引导下穿刺活检，24例病理诊断为骨髓瘤，1例为淋巴瘤，1例为软骨组织；5例手术取得病理；5例通过骨髓穿刺涂片诊断。16例化疗（其中4例有难以控制的骨痛，神经损害轻或进展缓慢者辅以放疗，1例行骨髓移植），其中9例伴神经功能损害，7例脊柱不稳定（因骨质疏松严重或一般状况差而不宜手术）；16例神经损害严重或进展迅速、脊柱不稳定者手术治疗（15例行化疗者中3例辅以放疗，1例行骨髓移植；2例行两次手术），其中14例伴神经功能损害，13例脊柱不稳定；2例放弃治疗；2例因失访而治疗不详。结果：32例获随访，平均随访31.5个月（2～108个月），20例存活，12例死亡，死亡者平均存活19.4个月（2～40个月）。化疗者6例死亡，1例失访，9例存活；存活者中3例伴神经功能损害，其中1例仅化疗，神经功能无明显改善；2例放疗+化疗，神经功能均有改善；5例脊柱不稳定，4例仅化疗，其中1例压缩骨折进一步加重，1例行放疗+化疗，症状缓解，但无随访影像学资料；7例患者化疗平均9.1个月后，病灶区未见明显成骨反应。16例手术者4例死亡，1例失访，11例存活，存活者中9例伴神经功能损害，其中77.8%（7/9）有神经功能改善；11例术前脊柱不稳定者，平均随访45.9个月，脊柱保持稳定；一期手术存活者有9例，3例前路，3例后路，3例前后联合入路，随访52个月（5～108个月），各手术入路患者临床效果相似。结论：CT引导下病灶穿刺活检是确诊MM的安全、有效的手段。放疗与手术均可改善MM患者的神经功能，但应严格掌握手术适应证。脊柱不稳定者可考虑手术治疗。

英文摘要:

  【Abstract】 Objective：To investigate the diagnosis and treatment protocols for spinal multiple myeloma（MM）.Methods:We retrospectively analyzed 36 spinal MM patients.The patients′ ages ranged from 34 to 78 years （mean，55.5 years）.All of the patients had pain as a major complaint and 25 cases suffered from neurologic deficits.CT guided needle biopsy was performed in 26 patients.24 cases were myeloma and the orther two cases were lymphoma and cartilage tissue.Pathologic results were obtained by surgery in 5 cases，and the last 5 cases were diagnosed by bone marrow smear.Chemotherapy or stem cell bone marrow transplantation was the first choice.Surgical indication was that the patients had severe or rapidly progressed neurologic deficit or spinal instability.The indication for radiotherapy was the patients having refractory pain and mild or slowly progressive neurologic impairment.16 cases received chemotherapy（4 cases had additional radiotherapy，1 case had bone marrow transplantation），in these cases，9 cases having neurologic deficit and 7 cases having spinal instability（they were excluded from surgery because of severe osteoporosis or poor general condition）.Surgeries were performed in 16 cases（15 cases had chemotherapy including 3 cases having additional radiotherapy，and 1 case had bone marrow transplantation.2 cases received second surgery due to incomplete resolution of symptoms），ａｎｄ　１４ cases having neurologic deficit and １３ cases having spinal instability．2 cases refused any treatment and 2 cases were lost to follow up.Results:32 cases were followed-up and the follow-up period was 2-108 months（average 31.5 months）.20 patients were still alive at the last follow-up.And 12 cases died with an average living period of 19.4 months（2-40 months）.In chemotherapy cases，6 cases died；1 case was lost to follow up；and 9 cases were alive.In the alive cases，3 cases had neurologic deficit，and 1 case received chemotherapy but no improvement of neurologic function.But improvements were observed in 100% of the 2 cases with chemotherapy and radiotherapy.In 5 alive cases with spinal instability，4 cases received chemotherapy only，and 1 of those showed progression of compression fracture of vertebra.Symptoms were relieved in the chemotherapy with radiotherapy case without any follow-up radiology image.In an average 9.1 months period，no apparent recalcification was detected in all the 7 cases with chemotherapy alone.In surgery cases， 4 cases died；1 case was lost to follow up；and 11 cases were alive.9 of the alive cases had neurologic deficit.77.8%（7/9） got neurologic improvement.In the 11 cases with spinal instability，spinal stability was remained in all of them in an average of 45.9 months′ follow-up.In 9 one-stage-surgery cases，3 patients were through anterior approach，3 patients were posterior approach and 3 patients were combined approach.In a period of 52 months′ follow-up，there were no diferent results.Conclusions:CT guided needle biopsy is valuable tool in the diagnosis of multiple myeloma.Neurologic function can be improved by radiotherapy or surgery，but the indications should be strictly controlled.Spinal instability is the indication for surgery.