脊柱轉(zhuǎn)移性疾病的診斷和治療

1、diagnosis and management of metastatic spine disease脊柱轉(zhuǎn)移性疾病的診斷和治療daniel m. sciubba, m.d., ftory j. petteys, m.d., mark b. dekutoski, m.d.,charles g. fsher, m.d.,f.r.c.s.c.,michael g. fehlings , m.d., ph.d., f.r.c.s.c.,stephen l. ondr a, m.d., laurence d. rhines, m.d., and ziya l. gokaslan, m.d.with

2、continued growth of the elderly population and improvements in cancer therapies, the number of patients with symptomatic spinal metastases is likely to increase, and this is a condition that commonly leads to debilitating neurological dysfunction and pain. advancements in surgical techniques of rese

3、ction and spinal reconstruction, improvements in clinical outcomes following various treatment modalities, generally in creased overall survival in patients with metastatic spine disease, and a recent ran domized trial by pat ch el i and colleagues demonstrating the superiority of a combined surgica

4、l/radiotherapeutic approach over a radiotherapy-only strategy have led many to suggest increasingly aggressive interventions for patients with such lesions. optimal management of spinal metastases encompasses numerous medical specialties, including n eurosurgery, orthopedic surgery, medical and radi

5、ati on on cology, radiology, and rehabilitati on medici ne. in this review, the clinical prese ntation, diag no sis, and management of spinal metastatic disease are discussed. ultimately, the goal of treatment in patients with spinal metastases remains palliative, and clinical judgment is required t

6、o select the appropriate patients for surgical intervention.隨著人口老齡化的加劇和癌癥治療方法的改進，有癥狀的脊柱轉(zhuǎn)移性疾病患者日漸增加，此類患者通常伴有 神經(jīng)功能障礙和疼痛。外科切除和脊林垂建技術(shù)的進步，多種治療模式改善了臨床治療效果，使脊柱轉(zhuǎn)移性 疾病患者總牛存率逐漸增加。patchell及其同事最近進行的一項隨機對比實驗證實外科/放療聯(lián)合療法比小純 放療更具優(yōu)越性，導(dǎo)致対此類患者采取積極干預(yù)的建議口益增多。脊柱轉(zhuǎn)移性病變的最佳治療手段需要多學(xué) 科協(xié)作，包括神經(jīng)外科、骨外科、腫瘤內(nèi)科、放療科、放射科以及康復(fù)科。本文就脊柱轉(zhuǎn)移性疾病

7、的臨床衣 現(xiàn)、診斷和治療措施做一綜述。最厲，脊柱轉(zhuǎn)移性疾病患者的治療1=1標(biāo)有待斟酌，臨床上要嚴(yán)格把握手術(shù)適 應(yīng)癥。key words: cancer, metastasis, spine, surgery, radiation therapy關(guān)鍵詞：癌癥轉(zhuǎn)移脊柱外科放療more than 1.4 million new cases of cancer will be diagnosed this year in the us.5 roughly half of these patients will eve ntually die of their disease, a rate that

8、has remained relatively un ch a nged for the past half century. complications related to cancer caused 565,650 deaths in 2008. the lungs and liver are the most frequent sites of distant metastases, followed closely by the skeleton, within which the spinal column is the most comm on site of metastasi

9、s.1,19,156 as many as 30-90% of patie nts who die of cancer are found to have spinal metastases in cadaver studies3°77£73“50gymptomatic secondary metastases are estimated to occur in approximately 10% of all cancer patients.130 up to 50% of spinal metastases require some form of treatment，

10、and 5-10% require surgical management.13,17,143,152 however, as survival rates for many primary cancers continue to improve, it is likely that the prevalence of spinal metastases will increase.今年，在美國將有14,000,000人口被診斷為癌癥的新發(fā)病例5。這些患者近一半將最終死于所患疾病，這樣 的死亡率保持半個世紀(jì)以來相對仍未改變。2008年，565,650人死于癌癥相關(guān)并發(fā)癥。肺和肝臟是遠處轉(zhuǎn)移 的

11、最常見部位，骨轉(zhuǎn)移緊隨其厲，而脊柱是骨轉(zhuǎn)移的最常見部位1j9j56o尸體研究發(fā)現(xiàn)，多達30-90%死于 癌癥的患者存在脊林轉(zhuǎn)移30,77,873"50。據(jù)估計，全部癌癥患者中大約°%存在有癥狀的繼發(fā)性轉(zhuǎn)移竹0。超 過50%的脊柱轉(zhuǎn)移瘤患者盂要某種方式的治療，5-10%患者需要外科治療13j7j43j52o然而，隨著原發(fā)腫瘤 牛存率的持續(xù)改善，或許脊柱轉(zhuǎn)移瘤的發(fā)病率將會下降。the highest incidenee of spinal metastases is found in individuals 40-65 years of age, corresponding t

12、o the period of highest cancer risk.107 males are slightly more prone to the development of spinal metastases, probably reflecting the slightly higher prevalence of lung cancer in men, and of prostate cancer over breast cancer.107 this disparity may vanish, however, as adjuvant therapies for breast

13、cancer increase the overall survival of patients with this disease, thus in creasing the period duri ng which lesions in the spine may arise. spinal metastases are most likely to originate from breast, lung, or prostate tumors, reflecting the high prevale nee of these tumors and their tende ncy to m

14、etastasize to bone.33,70 brihaye et al.23 found that 16.5% of symptomatic spine metastases arose from breast cancer, 15.6% from lung cancer, and 9.2% from prostate cancer.脊柱轉(zhuǎn)移瘤最高發(fā)于40-65歲人群，相應(yīng)也是癌癥最高發(fā)年齡段1°7。男性更傾向于罹患脊柱轉(zhuǎn)移瘤，這可能 與男性群體肺癌和前列腺癌發(fā)病率略高于女性乳腺癌有關(guān)107o然而，由于乳腺癌輔助療法增加了患者的整體 生存率，這種差異可能會消失，由此導(dǎo)致介并脊柱

15、轉(zhuǎn)移瘤的周期將增加。脊柱轉(zhuǎn)移瘤最有可能源自乳腺癌、 肺癌或前列腺癌，反映了這些腫瘤的高發(fā)病率和骨轉(zhuǎn)移的傾向性33,70。brihaye23等發(fā)現(xiàn)，冇癥狀的脊柱轉(zhuǎn)移 瘤16.5%源自乳腺癌,15.6%源自肺癌,9.2%源自前列腺癌。characteristics of metastatic tumors轉(zhuǎn)移瘤的特征metastatic lesions of the spine spread to the vertebral column by several mechanisms, including hematogenous seeding, direct extension or invas

16、ion, and by seeding in the csf. the mechanism of spread is often closely related to the biological behavior of the primary tumor. hematogenous spread, by venous or arterial routes, is thought to be the most common route by which primary tumors metastasize to the spine. because of the rich arterial b

17、lood supply of the vbs, tumor cells from distant primary lesions can travel to the spine and establish deposits of metastatic disease.6 spread via venous routes is often accomplished through the batson plexus, the iongitudinal network of valveless veins that connects vertebral veins with many other

18、beds of venous drainage, including the caval, portal, azygous, intercostal, pulmonary, and renal systems. changes in pressure within the major body cavities (for example, thorax, abdomen, and pelvis), can lead to variable flow through the plexus. as a result, tumor cells may be deposited in the spin

19、e via retrograde or antegrade venous flow.116 whether by arterial or venous routes, the hematogenous spread of tumors usually results in multicentric disease of the spine.轉(zhuǎn)移病灶通過多種機制侵入脊柱，包括血源性、直接蔓延和經(jīng)腦脊液播散。腫瘤播散機制為原發(fā)腫瘤的牛物 學(xué)行為密切相關(guān)。通過靜脈或動脈血源性播散被認(rèn)為是原發(fā)腫瘤轉(zhuǎn)移至脊柱的最常見途徑。由于椎體豐富的 動脈血供，艸瘤細(xì)胞i'l遠處原發(fā)灶轉(zhuǎn)移至脊柱并形成轉(zhuǎn)移性病

20、灶6。靜脈播散途徑通常通過batson叢完成， 即縱向無靜脈瓣的靜脈網(wǎng)，連接著椎靜脈和其他眾多靜脈冋流通路，包括腔靜脈、門靜脈、奇靜脈、肋間靜 脈、肺靜脈和腎靜脈系統(tǒng)。主要體腔(例如，胸腔、腹腔和盆腔)的壓力發(fā)生變化時，導(dǎo)致血液通過batson從 發(fā)牛變流，結(jié)果使腫瘤細(xì)胞通過逆行或順行靜脈流滯留丁-脊tt116o無論動脈或靜脈途徑，腫瘤血源性播散通 常引起脊柱多發(fā)性病變。direct extension of primary tumors may also lead to metastases in the spine. lesions within the thorax, abdomen,

21、or pelvis may become locally aggressive and invade the vertebral column, leading to symptomatic spinal metastases tumors of the lung can extend posteriorly into the thoracic spine or superiorly to involve the cervicothoracic junction. additi on ally, prostate, bladder, and colorectal cancers may inv

22、ade the lumbar or sacral spine.116原發(fā)腫瘤直接蔓延也可引起脊柱形成轉(zhuǎn)移灶。胸部、腹部或盆部病變可局部浸入脊柱，引起冇癥狀的脊柱轉(zhuǎn) 移斕。肺癌可向后浸入胸椎或向上浸入包括頸胸連接處。另外，前列腺、膀胱和結(jié)直腸癌可浸入腰椎或紙椎 116ometastasis to the spine or spinal cord can also occur via shedding or seeding of tumor cells in the csf. thisusually occurs after surgical manipulation of cerebral or

23、 cerebellar metastatic or primary lesions, and5 like hematogenous spread, often leads to multicentric disease.108腫瘤細(xì)胞可通過腦脊液屮脫落或種植形成脊柱或脊髄轉(zhuǎn)移瘤。這通常發(fā)牛在大腦或小腦轉(zhuǎn)移性或原發(fā)性腫瘤 術(shù)后，類似血源性播散，引起多發(fā)性病變卬8。spinal tumors are classically grouped into 3 categories based on anatomical distribution: extradural, intradural-extra

24、medullary, and intramedullary.84,104 the overwhelming majority of all spinal metastases are found in the extradural compartment; that is, the bony spine and associated tissues metastases to the extradural compartment are found most commonly in the vb, with or without extension into the posterior ele

25、ments, followed by the paravertebral regions and the epidural space, respective!y. intradural and intramedullary metastases are very rare, and are often due to csf seeding低 all segments of the vertebral column are susceptible to distant metastasis, but the thoracic spine is by far the most frequent

26、site (70%),followed by the lumbar spine (20%),cervical spine，and sacrum, respectively.116脊柱腫瘤依據(jù)解剖學(xué)分布分為3類：硬膜外、硬膜內(nèi)髓外、髄內(nèi)84j04o絕大多數(shù)脊柱轉(zhuǎn)移瘤發(fā)生在碩膜外, 即脊柱骨性部分和伴隨組織。破膜外轉(zhuǎn)移瘤大部分發(fā)牛在椎體，伴或不伴有向椎體后方浸潤，其次為椎旁區(qū) 域和硬膜外腔。硬膜內(nèi)和髓內(nèi)轉(zhuǎn)移瘤很少見，且通常經(jīng)過腦脊液播散1°8。脊柱全部節(jié)段均對發(fā)生轉(zhuǎn)移瘤，但 是胸椎為最常見部位(70%),其次為腰椎(20%)、頸椎和紙椎1怡。presentation of metasta

27、tic tumors轉(zhuǎn)移瘤的臨床表現(xiàn)metastatic disease of the spine may cause a constellation of symptoms, including pain, motor or autonomic dysfunction, or sensory dysfunction, depending on the rate of tumor growth, degree of bone involvement or destruction,amount of neural compression, and extent of systemic disea

28、se. tumors that grow quickly may lead to rapid progression of symptoms. lytic tumors may lead to pathological fractures or deformities due to bone destruction. metastatic tumors may also lead to nerve root impingement or spinal cord compression, leadi ng to radiculopathy or myelopathy, respectively.

29、 additi on ally, signs of systemic disease may be prese nt, including weight loss, anorexia, or organ dysfunction. physical examination may reveal palpable paraspinal or even rectal masses in the case of large sacral metastases.145脊柱轉(zhuǎn)移瘤可引起一組癥候群，包括疼痛、活動性或口主性功能障礙或感覺障礙，這些主要取決丁腫瘤牛氏 速度、骨質(zhì)受累和破壞程度、神經(jīng)受壓程度和系

30、統(tǒng)性疾病的程度。腫瘤牛長迅速可導(dǎo)致癥狀迅速進展。溶解 性腫瘤市丁骨折破壞，可導(dǎo)致病理性骨折或畸形。轉(zhuǎn)移瘤也可導(dǎo)致神經(jīng)根受累和脊髓受壓，相應(yīng)引起神經(jīng)根 病和脊髓病。另外，可表現(xiàn)出系統(tǒng)性疾病的體征，包括消瘦、食欲減退或器官衰竭。對于體積大的紙骨轉(zhuǎn)移 瘤病例中，體格檢查可發(fā)現(xiàn)明顯的椎旁其至直腸團塊145opain symptoms疼痛the most common presenting symptom of patients with symptomatic spinal metastases is pain, which occurs in 83-95% of patients, and may

31、precede the development of other neurological symptoms by weeks or months.10,70,113,145,152 pain related to spinal metastases may actually be the initial symptom in as many as 10% of cancer patients.92 three classically defined types of pain often affect patients with symptomatic spinal metastases,

32、including local, mechanical, and radicular pain. patients may be affected by only one of these types of pain, or they may experience various combinations of these different entities distinguish!ng the type of pain a particular patient has is a pivotal part of the evaluation process local pain is tho

33、ught to result from periosteal stretching and inflammation caused by tumor growth, and is described as a deep “gnawing” or “aching” pain. it may improve with activity, is often nocturnal, and is responsive to antiinflammatory or corticosteroid medications.63 percussion or palpation over the spinous

34、process may elicittenderness in patients with this type of pain.疼痛是冇癥狀的脊柱轉(zhuǎn)移瘤患者中最常見的主訴，83-95%的患者均可發(fā)生，較其它神經(jīng)癥狀早發(fā)數(shù)周或數(shù) 月10.70,113.145,152o 1 q%的癌癥患者首發(fā)癥狀即為脊柱轉(zhuǎn)移瘤相關(guān)性疼痛叭三種典型的疼痛類型常影響冇癥 狀的脊柱轉(zhuǎn)移瘤患者，包括局部疼痛、機械性疼癰和神經(jīng)根性疼痛?；颊呖赡苁苓@些疼痛類型中的一種影響， 或者經(jīng)受不同類型聯(lián)合的影響。區(qū)別個別患者疼痛的類烈是診斷評估過程的關(guān)鍵部分。局部疼痛是山于腫瘤 生長引起骨膜拉伸和炎癥而引起，被描述為深部“咬噬性”或“

35、酸痛性”疼痛。常發(fā)生在夜間，活動厲緩解，應(yīng)用 抗炎藥或皮質(zhì)激索類藥物町迅速緩解63o對此型疼痛患者進行棘突叩診或觸診時可引起扣、壓痛。un like local pain, mecha nical back pain is often refractory to an tiinflammatory and pain medicines, and varies with position or activity. this type of pain is ascribed to impending or established instability. tumors that cause def

36、ormity or collapse of the affected vbs often lead to spinal instability and in creased strain on the support and stability elements of the spine; that is, muscles, tendons5 ligaments, and joint capsules. this strain leads to characteristic pain with movement or axial loading of the spine. alternativ

37、ely, this pain may be elicited by lying prone or supine, but is often relieved with lying down, usually on one's side. mechanical pain often responds well to stabilization of the spine with bracing or surgical fixation.不同于局部疼痛，機械性背痛應(yīng)用抗炎藥和止痛藥通常無效，隨姿勢和活動血變化。此種類型的疼痛歸咎于 將要形成或己經(jīng)形成的不穩(wěn)。艸瘤引起的畸形或受累椎體壓縮常導(dǎo)

38、致脊柱不穩(wěn)，增加了脊柱支撐和穩(wěn)定結(jié)構(gòu) 的張力，這些結(jié)構(gòu)包括肌肉、肌腱、韌帶和關(guān)節(jié)囊。這種張力引起脊柱運動或軸向負(fù)荷的特征性疼痛。另外， 這種疼痛可在俯臥位或仰臥位誘發(fā)，但是側(cè)臥位吋通?？删徑?。佩戴支具或行手術(shù)固怎以穩(wěn)泄脊林可較好的 緩解機械性疼痛。radicular pain related to spinal metastases occurs when tumors compress nerve roots as the roots exit the spine, or is due to pathological fractures that obliterate the neural

39、foramina, leading to nerve root impingement like radicular pain associated with intervertebral disc herniation, it is often described as sharp, shooting, or stabbing in nature. intradural extramedullary metastases may cause irritation or impingement of nerve roots within the dura mater, leading to d

40、ysesthetic or neuropathic pain. unlike typical radicular pain, this is often described as an in tense, burni ng sen sat i on°*當(dāng)腫瘤壓迫脊柱神經(jīng)根出口處的神經(jīng)根時，或者由于壓縮性骨折閉塞了神經(jīng)根管，侵犯神經(jīng)根時，可發(fā)生脊 林轉(zhuǎn)移瘤神經(jīng)根性疼痛。類似于椎間暗盤突出相關(guān)的根性疼痛，常被描述為劇烈、穿透樣刺痛。偵膜內(nèi)髓外 轉(zhuǎn)移瘤可引起刺激或侵犯神經(jīng)根，引起鈍性或神經(jīng)根性痛。與典型的神經(jīng)根痛不同，此種疼痛常被描述為劇 烈的燒灼感28。neurological dysf

41、unction神經(jīng)功能障礙motor dysfunction is the next most common symptom of patients with metastatic disease of the spine weakness in one or more muscle groups is found in 60-85% of patients with mescc.66,70,113 this weakness may be related to myelopathy (long tract signs), radiculopathy, or some combination

42、of the two. it is due to direct compression of neural structures by tumor, or to a pathological fracture that leads to retropulsion of bone fragments into the spinal canal or neural foramina. patients with mescc may also have some degree of autonomic dysfunction manifesting as bowel, bladder, or sex

43、ual abnormalities that are often not revealed to the physicia n un less a direct inq uiry is made. 124 the most com mon autonomic finding in mescc is bladder dysfunction (often urinary retention), which usually correlates well with the degree of motor impairment. patients with motor dysfunction usua

44、lly progress to complete paralysis without treatment.20脊林轉(zhuǎn)移瘤患者下一個最常見癥狀是運動功能障礙o 60-85%的轉(zhuǎn)移性脊髄碩膜外壓迫癥(mescc)患者存在一 組或多組肌群肌無力66701113o這種肌無力可能和脊齟病(長朿征)、神經(jīng)根病或合并此兩種疾病冇關(guān)。這是由 丁腫瘤直接壓迫神經(jīng)結(jié)構(gòu)，或病理性骨折導(dǎo)致骨折塊突入椎管或神經(jīng)根管。mescc患者町能冇不同程度的口主性功能障礙表現(xiàn)，例如腸、膀胱或性功能異常，除非更師直接問診，否則這些表現(xiàn)常不被發(fā)現(xiàn)12一 mescc 患者最常見的自發(fā)癥狀為膀胱功能障礙（通常為尿潴昭），這與運動功能障礙程

45、度明顯相關(guān)。運動功能障礙患 者如不治療，通常發(fā)展成為完全癱瘓'°。sensory disturbances including anesthesia, hyperesthesia, and paresthesia usually occur in concert with motor dysfunction and pain in the corresponding dermatomal distributions. patients with myelopathy may report sensory abnormalities in a bandlike distribu

46、tion across the chest or abdomen. in mescc of the thoracic cord, patients may describe a feeling of discomfort in the chest that is likened to restriction by a tight shirt or corset, similar in nature to the sensory discomfort described by patients with transverse myelitis of the thoracic cord. 127感

47、覺障礙血括麻痹、感覺過嫩，感覺界常通常與運動功能障礙和與皮區(qū)相應(yīng)的疼痛同步發(fā)生，脊髓病患者可 能心在胸腹部帶狀分布的感覺異常。胸髓mescc患者可能描述-種胸部不適感，類似襯衫或胸衣過緊的感覺， 木質(zhì)上與胸髓橫慣性脊髓炎患者描述的感覺不適類似。the patienfs neurological function when a diagnosis of spinal cord compression is made usually correlates well with their prog no sis.6,71 this observation underscores the import

48、ance of diag nosis before motor or autonomic deficits occur. most patients will have pain before these deficits appear. however, because reports of back pain are very common in the general population, with a lifetime prevalence of up to 84% in some studies,26 a delay in diagnosis occurs in many case

49、s of vertebral metastasis in which the initial complaint is one of new-onset back or neck pain.127 in 2002, levack et al.88 reported that in 319 patients with cancer, a median 2-month delay occurred between the report of pain to a primary care provider and the diagnosis of cord compression. therefor

50、e, clinicians should maintain a high index of suspicion for vertebral metastases in patients with back pain and a known history of cancer, with conditions that predispose them to the development of cancer5 or with high-risk profiles for cancer. additionally, because pain due to nonneoplastic process

51、es is less common in the thoracic spine than the cervical or lumbar spine, pain in this region should raise the suspicion of cancer.127當(dāng)脊髓壓迫診斷明確時，患者神經(jīng)功能與其預(yù)厲密切相關(guān)671 o這些觀察強調(diào)了運動和口主功能障礙發(fā)生之前 明確診斷的重要性。人多數(shù)患者在這些障礙發(fā)生前即可有疼痛的癥狀。然而，由于背痛的報道在普通人群中 非常普遍，一些研究稱其終生患病率超過84%,診斷延謀常發(fā)生在最初主訴為新發(fā)背痛或頸痛的脊柱轉(zhuǎn)移瘤 患者中2002年，levack等報

52、道，319名癌癥患者，診斷延誤平均2刀，發(fā)生在向初級醫(yī)療服務(wù)提供 者報告疼痛和脊髓壓迫確診z間。因此，臨床醫(yī)師應(yīng)對背痛或既往腫瘤病史、患者有傾向于榷患腫瘤的條件 或存在腫瘤高風(fēng)險狀況的脊柱轉(zhuǎn)移瘤患者保持高度警覺。另外，胸椎與頸椎、腰椎相比，非腫瘤引起的疼痛 不常見，因此這個區(qū)域出現(xiàn)疼痛應(yīng)考慮到腫瘤1”。diagnostic work-up診斷性病情檢査patients with suspected spinal metastasis should have a thorough diagnostic work-up, including history and physical exami n

53、ation. warning signs in elude symptoms of vertebral lesions （nocturnal pain, n eurological dysfunction, and gait disturbanee） as well as those of systemic disease （weight loss or organ dysfunction）. smoking history, environ mental or occupati onal exposure, and travel history should be in vestigated

54、 inq uiries should also be made about conditions that in crease the likelihood of can cer （hiv, in flammatory conditions, carcinoma in situ） as well as recent cancer scree ning exami nations and family hist ory. blood cell counts, chemistry, and prostate specific antigen should be examined, and seru

55、m and urine protein electrophoresis should be obtained when there is concern about multiple myeloma.懷疑脊林轉(zhuǎn)移瘤的患者應(yīng)該做徹底的診斷性檢査，包括病史打體格檢杳。警示信號包括脊椎損害癥狀（夜間痛、 神經(jīng)功能障礙、步態(tài)不穩(wěn)）和系統(tǒng)性癥狀（體重減輕和器官功能障礙）。調(diào)查患者吸煙史、環(huán)境或職業(yè)性暴露史 和旅游史。問診應(yīng)涉及町增加癌癥可能性的條件（hiv、炎癥性條件和原位癌）以及最近的癌癥篩查情況和家族史。檢測血細(xì)胞記數(shù)、?；傲邢偬亻_性抗原，當(dāng)考慮到多發(fā)性骨髓瘤時，加做血漿和尿蛋白電泳分析。ima

56、ging studies影像學(xué)研究plain radiographs have long been a mainstay in the initial evaluation of patients with new symptoms related to the spine this is mainly because of the technical ease of obtaining these studies, their low cost, and widespread use. consequently, plain radiographs are a useful screenin

57、g test to identify lytic or sclerotic lesions, pathological fractures, spinal deformities, and large masses breast or prostate cancers may produce sclerotic or blastic lesions* but most spinal metastases are lytic, and plain radiographs may not reveal cha nges until up to half of the vb is affected.

58、56,102 due to this relative in sensitivity, diag nosis is ofte n obtained with other imaging techniquesx線平片長期以來作為出現(xiàn)與脊柱相關(guān)的新發(fā)癥狀患者的初級評估手段。這主要由于其技術(shù)簡易、價格低廉 和廣泛的應(yīng)用。因此，x線平片成為確認(rèn)溶解性和硬化性損害、病理性骨折、脊柱畸形和人體積團塊的有效 篩查檢測工具。乳腺癌和前列腺癌可產(chǎn)生碩化性損害28,但是大多數(shù)脊柱轉(zhuǎn)移瘤屬于溶解性的，在超過半個 椎體受累前，x線平片不能顯示和關(guān)變化56j02c由于這種相對不敏感性，明確診斷常需耍結(jié)合其它影像學(xué)技 術(shù)

59、。nuclear scintigraphy （bone scan） is a sensitive method for identifying areas of increased metabolic activity throughout the skeletal system. whereas tumor-related changes visible on plain radiography may not be prese nt until 30-50% of vertebral bone is eroded,56,102 bone sea ns can detect metastases earlier96 and with resolution to as small as 2 mm.152 the sensitivity of nuclear bone scans in detecting vertebral metastases has been reported to be 62-89%.109 however, because nuclear scans detect increased metabolic activity, they