手术治疗颈椎转移瘤的疗效及预后的影响因素

Analysis of factors affecting the prognosis and operative effect of patients with cervical metastasis

中文关键词:  颈椎转移瘤  外科治疗  预后影响因素

英文关键词:Surgical treatment  Metastatic cancer  Prognosis  Influencing factors

中文摘要:

  【摘要】 目的：探讨手术治疗颈椎转移瘤的疗效以及预后的影响因素。方法：回顾性分析2011年1月~2018年12月，我科手术治疗并获随访的颈椎转移瘤患者72例，其中男性47例，女性25例，年龄23~78岁，平均56.7±12.5岁。其中单发颈椎转移20例，多发颈椎转移52例，主要责任节段：C1~C2 5例，C3~6 51例，C7~T1 16例，病程（从出现症状到诊断为转移瘤时间）15d～4年，术前Frankel分级：A级7例，B级16例，C级23例，D级23例，E级3例。收集患者术前临床资料，根据患者病情分别行肿瘤切除和姑息分离手术治疗。通过患者生存期评估患者预后，通过术前、术后2周、末次随访时术前进行日本骨科协会（Japanese Orthopaedic Association，JOA）评分、卡氏（Karnofsky，KPS）评分评估手术疗效。采用单因素分析颈椎转移瘤手术治疗后的预后影响因素，包括：性别、原发肿瘤性质、累及椎体节段、是否多发转移、合并其他脏器转移、病程、术前是否放化疗、肿瘤切除方式等。将单因素分析差异有统计学意义的因素纳入COX回归模型分析，评估影响颈椎转移瘤患者预后危险因素。根据患者术后JOA改善率将患者分为优良组（改善率≥50%）和一般组（改善率＜50%），并进行疗效影响因素分析，包括：术前神经症状持续时间、肿瘤是否多发转移、累及椎体节段、脊柱肿瘤不稳定评分系统（spine instability neoplastic system，SINS）评分等。结果：手术时间50~230min，平均155.85±62.75min，术中出血50~1500ml，平均590.78±556.24ml。患者术后均有不同程度疼痛缓解。术前颈椎JOA评分为8.44±5.22分，术后2周为12.35±4.82分，末次随访为12.96±3.82分，术后2周和末次随访较术前明显改善（P＜0.01）。术前Karnofsi评分为52.22±15.08分，术后2周为66.54±15.21分，末次随访为68.15±12.37分，术后2周和末次随访的Karnofsi评分较术前明显改善（P＜0.01）。患者中位生存期为740d（24.7个月）。经单因素分析，原发肿瘤性质（生长速度）和是否合并其他脏器转移作为有统计学意义的因素纳入COX回归模型分析，表明“合并其他脏器转移”是影响颈椎转移瘤患者预后危险因素（P＜0.05）。分析疗效的影响因素表明，术前病程、术前Frankel分级和SINS评分对术后JOA改善率的影响有统计学意义（P＜0.05）。结论：对于颈椎转移瘤患者，合并其他脏器转移是影响其预后的危险因素。早期发现转移病灶，评估脊柱稳定性，出现神经功能障碍早期手术的患者有更好的JOA改善率。

英文摘要:

  【Abstract】 Objectives: To investigate the surgical efficacy, survival prognosis of patients with cervical spine metastasis. Methods: A retrospective analysis was conducted on 72 patients with cervical spine metastasis treated by surgery in our department and followed up from January 2011 to December 2018. There were 47 males and 25 females, aged from 23-78 years old, with an average age of 56.7±12.5 years old. Of all patients, 20 were with single segmental metastasis, 52 were with multiple segmental metastases, and the main responsible segments were C1-2 5 cases, C3-6 51 cases, C7-T1 16 cases. The course of disease(from the onset of symptoms to the diagnosis of metastatic cancer) was 15d to 4 years. Preoperative Frankel classification: grade A in 7 cases, grade B in 16 cases, grade C in 23 cases, grade D in 23 cases, and grade E in 3 cases. Tumor resection and palliative separation were performed according to the patient′s condition. The surgical efficacy of the patients was evaluated by JOA score and Karnofsi score at preoperation, 2 weeks after operation, and at the last follow-up. Univariate analysis of prognostic factors after surgical treatment of cervical metastasis includedgender, nature of primary tumor, the vertebral segments involved, whether multiple segments were involved or combined with other organic metastases, duration of preoperative neurological symptoms, whether received preoperative radiotherapy and chemotherapy, and methodsof tumor resection. After univariate analysis, factors with statistically significant differences were included in the COX regression model to evaluate the risk factors that affect the prognosis of patients with cervical metastasis. Patients were divided into excellent group(JOA improvement rate ≥50%) and general group(JOA improvement rate <50%) according to the postoperative JOA improvement rate. The factors affecting the efficacy were analyzed: including the duration of preoperative neurological symptoms, whether the tumor had multiple metastases, vertebral segments involved, and SINS score. Results: The operative duration was 50-230min, with an average of 155.85±62.75min, and the intraoperative blood loss was 50-1500ml, with an average of 590.78±556.24ml. All patients had varying degrees of pain relief after surgery. The preoperative JOA score of the cervical spine were 8.44±5.22, 12.35±4.82 after 2 weeks, and 12.96±3.82 at final follow-up, showing significant improvement compared with preoperation(P<0.01). The Karnofsi score before surgery was 52.22±15.08, 66.54±15.21 at 2 weeks postoperatively, and 68.15±12.37 at final follow-up. The Karnofsi scores at 2 weeks postoperatively and at final follow-up were significantly improved compared with preoperatively(P<0.01). The median survival time of 72 patients was 740 days(24.7 months). After univariate analysis, the nature of the primary tumor and whether it was combined with other organic metastases were included as statistically significant factors into the COX regression model analysis. The results showed that "whether it was combined with other organ metastases" affected the prognosis of patients with cervical metastasis as risk factor(P<0.05). In addition, analysis of the results of both groups showed that the duration of preoperative neurological symptoms, preoperative Frankel classification and SINS score had statistically significant effects on the postoperative JOA improvement rate(P<0.05). Conclusions: For patients with cervical spine metastasis, whether combining with other organ metastases is a risk factor affecting their prognoses. Patients with early detection of metastatic lesions, assessment of spine stability, preoperative neurological symptoms lasting less than 72h or with neurological dysfunction in early stage have a better JOA improvement rate.