脊柱骨髓瘤的手术治疗效果及预后分析

Spinal myeloma: surgical outcome and prognostic factors

中文关键词:  脊柱  骨髓瘤  外科治疗  预后

英文关键词:Spine  Myeloma  Surgical treatment  Prognostic

中文摘要:

  【摘要】 目的：明确脊柱骨髓瘤患者手术治疗后生活质量、疼痛症状和神经功能的改善程度、生存情况及其预后相关因素，为探讨脊柱骨髓瘤合理的手术治疗方案提供依据。方法：回顾性分析2003年3月至2012年3月于我中心接受手术治疗的85例脊柱骨髓瘤患者资料, 其中男性47例，女性38例，就诊时平均年龄64.8岁（43～83岁）。病变位于颈椎18例，胸椎41例，腰骶椎26例。患者症状包括局部疼痛70例（82.3%）、神经根性症状30例（35.3%），脊髓压迫症状37例（43.5%）等。手术方式为开放手术75例（其中联合椎体成形术15例）；经皮椎体成形术（PVP）10例。对患者疼痛视觉模拟量表评分（visual analogue scale，VAS）、脊髓损伤Frankel分级，美国东部肿瘤协作组（Eastern Cooperative Oncology Group，ECOG）一般状况评分在术后的改善程度、生存及预后因素进行分析。其中手术效果（VAS评分/ECOG评分/Frankel分级）的分析采用配对t检验。手术出血量的影响因素（手术方式、术前化疗或栓塞等）采用单因素方差分析。采用Kaplan-Meier法计算生存率，收集患者年龄、性别、疾病分期、病变数目以及实验室检查（血红蛋白、肌酐、C反应蛋白、B2微球蛋白、白蛋白、血钙、乳酸脱氢酶等）作为预后因素进行单因素及多因素分析，分析均采用Cox回归模型。结果：本组患者平均手术时间为258min，出血量 1928.48ml，术后患者的一般情况、疼痛程度、神经功能均有明显改善（P<0.01）。术前化疗、栓塞并未显著减少减压固定组患者的出血量，而对于病灶清除性手术的患者而言，术前化疗、栓塞可减少术中出血量。术后2例患者出现局部复发，在本组患者中并发症发生率为10.5%（9/85）。中位生存期39个月，1年、3年、5年总体生存率分别为93.9%、70.6%、50.6%。Cox回归模型最终结果显示C反应蛋白（P<0.01，95%CI 1.87～12.94）、乳酸脱氢酶水平（P<0.01，95%CI 2.19～11.25）是影响预后的独立危险因素。结论：目前的手术治疗方式可明显缓解患者症状，并发症发生率低，患者术后整体生存时间较长。C反应蛋白、乳酸脱氢酶水平是影响预后的独立危险因素。

英文摘要:

  【Abstract】 Objectives: To identify the clinical outcome and the survival prognostic factors of the patients with spinal myeloma, and to investigate the optimized surgical treatment strategy of the disease. Methods: The clinical data of the 85 patients with spinal myeloma who underwent surgeries in our center from March 2003 to March 2012 were reviewed retrospectively. 47 males and 38 females were enrolled with an average age of 64.8 years(ranged from 43 to 83 years). 18 cases had tumors located in cervical spine, 41 in thoracic spine and 26 in lumbar spine. 70 patients(82.3%) presented with local pain, 30 with radicular symptoms(35.3%), and 37 cases(43.5%) with spinal cord compression. Open surgery was performed in 75 cases, wile 10 patients received percutaneous vertebroplasty(PVP). Open surgery combined with vertebroplasty was performed in 15 cases. The postoperative pain relief, neurological function and quality of life and their influence factors via visual analogue scale(VAS), Eastern Cooperative Oncology Group(ECOG) score and Frankel classification were analyzed. The analysis of the optimization of VAS, ECOG score and Frankel classification was performed by paired t test. One-way anova was used to analyze the influence factors of total blood loss. The survival rate was analyzed by Kaplan-Meier method. The prognostic factors including age, gender, stage of disease, number of lesions, hemoglobin, Creatinine, C-reaction protein, Lactic acid dehydrogenase levels were analyzed univariately and multivariately by Cox comparative hazard model. Results: Among all 85 cases, 18 cases received cervical spine surgery, 41 cases received thoracic spine surgery and 26 received lumbosacral spine surgery. 70(82.3%) patients presented with local pain, 30 cases(35.3%) with radicular symptoms, and 37 patients(43.5%) with symptoms due to spinal cord compression. The average operation time was 258min and the average blood loss was 1928.48ml. The degree of pain, neurological function and quality of life were improved significantly(P<0.01). Preoperative chemotherapy(P<0.01) and vascular embolization(P=0.03) reduced blood loss during surgery. 2 patients had local recurrences. The overall complication rate was 10.5%(9/85). The median survival time was 39 months. The overall survival rate at 1 year, 3 years and 5 years was 93.9%, 70.6% and 50.6%, respectively. C-reaction protein(P<0.01, 95%CI 1.87-12.94) and Lactate dehydrogenase level(P<0.01, 95%CI 2.19-11.25) were the prognostic factors of postoperative survival. Conclusions: The current surgical strategy of spinal myeloma is effective to relieve symptoms. The complication rate is low. The overall survival time is long in spinal myeloma patients. C-reaction protein and Lactate dehydrogenase level are the prognostic factors of postoperative survival.