脊柱轉移性疾病課件

metastaticspinedisease:EvolutionXUWENBINSIRRUNRUNSHAWHOSPITALmetastaticspinedisease:Evol1backgroundIntheUSA,nearly300000adultshaveosseousmetastaticdisease,withapproximately60%ofthemetastasesbeingspinalmetastases.Approximately10%ofpatientswithspinalmetastasesdevelopspinalcordcompression—asevereandoftenpermanentlydisablingconditionthatisanoncologicalemergency.Historically,spinalmetastaseshavebeentreatedwithinvasivesurgicalapproaches(eg,en-blocresection),orlow-dosepalliativeconventionalexternal-beamradiotherapy(EBRT),orboth.backgroundIntheUSA,nearly32脊柱轉移性疾病課件3backgroundEvolutionofsurgerycanbetracedfrominappropriateopensurgery(i.e.laminectomy)toappropriateopen(i.e.posteriorinstrumentationanddecompression)andfurthertominimallyinvasivesurgery.Presently,thebestclinicaloutcomesareachievedbysurgerywithtimelypostoperativeradiotherapy.

spinestereotacticbodyradiotherapy(SBRT),spinestereotacticradiosurgery(SRS)backgroundEvolutionofsurgery4Primarysite乳腺22%肺15%前列腺10%黑色素瘤9%淋巴瘤7%胃腸道5%腎臟6%甲狀腺3%男性：肺癌，前列腺癌，腎癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宮癌、甲狀腺癌、結腸癌、胃癌。Primarysite乳腺22%男性：肺癌，前列腺癌，腎癌5Lifeexpectancy肺癌：術后4月結腸癌：7月腎癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲狀腺癌：10年（80-95%）1年：48%5年：1.5%Lifeexpectancy肺癌：術后4月1年：48%6InvolvedsegmentAutopsystudieshavedemonstratedthelumbarspinetobemostcommonlyinvolved,followedbythethoracicandcervicalsegments.Clinically,symptomaticspinalmetastasesaremostoftenlocalizedtothethoracicspine(withspecialpredilectionforthesegmentsaboutT4andT11),followedbythelumbarandcervicalsegments.Thoracic70%Lumbar20%Cervical10%InvolvedsegmentAutopsystudie7metastasispathwayHematogenousmetastasis：Batson’svenousplexus，cancerembolusLymphaticmetastasisImplantationmetastasisCSFmetastasismetastasispathwayHematogenous8Clinicalmanifestation疼痛是最常見的癥狀，約有70%患者以疼痛起病。疼痛常逐漸變?yōu)槌掷m(xù)性加劇，夜間痛明顯，制動多無效。嚴重者止痛藥無效。大約有50%的胸脊髓損害患者在脊髓壓迫癥狀出現(xiàn)時即表現(xiàn)出神經根性疼痛。疼痛因病癥部位不同而異。

由于轉移瘤主要位于椎體，往往從前方壓迫椎體束或前角細胞，故運動功能損害常先出現(xiàn)。與其他脊髓病損類似，括約肌功能損害常提示不良預后。以脊柱轉移為首發(fā)癥狀的為10%。Clinicalmanifestation疼痛是最常見的癥9RadiologicalexamX線平片是脊柱轉移瘤診斷最基本的影像學檢查方法，常表現(xiàn)為骨質疏松、溶骨性或硬化性改變，以椎弓根消失（貓頭鷹眨眼征）、椎體塌陷較常見，椎間隙通常正常。博蘭（Boland）等認為椎體的扁平壓縮比楔形變更有意義。相比X線平片，核素全身骨掃描可提前3~6個月發(fā)現(xiàn)骨性損害，其靈敏度高達95%~97%,多表現(xiàn)為放射性濃聚，對可疑骨轉移瘤患者應盡量作骨掃描檢查。對于椎體破壞及椎旁、椎管內占位性病變，應用CT檢查顯示較清楚，但當病變較小、CT掃描層距較寬時，容易漏診。對于軟組織病變檢查，MRI可提供比X線平片、同位素、CT等檢查更精確的影像學信息。對于選擇治療方法、手術進路等都具有重要的實用價值。

RadiologicalexamX線平片是脊柱轉移瘤診斷10脊柱轉移性疾病課件11脊柱轉移性疾病課件12questionsGlobalperformancestatus?Lifeexpectancy?Mechanicalstableorunstable?Surgery,radiotherapy,orchemotherapy?Whensurgery?Radiotherapybeforeorafterthesurgery?Howlong?Medicinechoose,Steroidetc?questionsGlobalperformancest13脊柱轉移性疾病課件14脊柱轉移性疾病課件15KPS評分References:

Crooks,V,WallerS,etal.TheuseoftheKarnofskyPerformanceScaleindeterminingoutcomesandriskingeriatricoutpatients.JGerontol.1991;46:M139-M144.

deHaanR,AaronsonA,etal.Measuringqualityoflifeinstroke.Stroke.1993;24:320-327.

HollenPJ,GrallaRJ,etal.Measurementofqualityoflifeinpatientswithlungcancerinmulticentertrialsofnewtherapies.Cancer.1994;73:2087-2098.

O'TooleDM,GoldenAM.Evaluatingcancerpatientsforrehabilitationpotential.WestJMed.1991;155:384-387.

OxfordTextbookofPalliativeMedicine,OxfordUniversityPress.1993;109.

SchagCC,HeinrichRL,GanzPA.Karnofskyperformancestatusrevisited:Reliability,validity,andguidelines.JClinOncology.1984;2:187-193.KPS評分References:

Crooks,V,Wa16ToMITa評分Tomita等對67例脊柱轉移性腫瘤患者進行回顧性分析并總結制定新的預后評分系統(tǒng)，根據(jù)腫瘤惡性程度、臟器轉移及骨轉移情況進行評價，總分2~10分，根據(jù)不同評分指導選擇不同治療方案。前瞻性研究顯示其預期生存時間和實際生存時間符合率為84%。注重預后，沒有把神經壓迫考慮進去。

ToMITa評分Tomita等對67例脊柱轉移性腫瘤患者進行17Tomita評分Tomita評分18修正的Tokuhashi評分提示平均生存時間Zou等研究認為，修正的Tokuhashi評分系統(tǒng)對于短期預后的判斷較為準確，而Tomita評分系統(tǒng)則更適用于長期預后結果的推測。ZouXN,GrejsA,LiHS,etal.Estimationoflifeexpectancyforselectingsurgicalprocedureandpredictingprognosisofextraduralspinalmetastases[J].AiZheng，2006，25(11):1406—1410.修正的Tokuhashi評分提示平均生存時間ZouXN,19脊柱轉移性疾病課件20脊柱轉移性疾病課件21脊柱轉移性疾病課件22SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對SINS系統(tǒng)進行可信度及有效性分析，認為其預測準確性較好，靈敏度和特異度分別為95.7和79.52%。但SINS系統(tǒng)僅針對病灶局部穩(wěn)定性進行評價，并未考慮患者全身情況，僅能用于制定局部治療方案，無法對患者預后進行評估。SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對23Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經常用于評價脊柱的穩(wěn)定性。kostuik分脊椎成六柱，包括椎體十字分割的四柱，和后部的兩柱，并提出腫瘤占三柱或更多時會出現(xiàn)脊柱不穩(wěn)，而當腫瘤累及五個或更多柱時，脊柱不穩(wěn)更加嚴重。他還提出，椎體塌陷角為20°或更大時為脊柱不穩(wěn)。這種分類是一種有用的準則，但也并非適用任何情況，因為有時腫瘤可能侵犯三或更多的部分，而不引起癥狀。1-2部分破壞屬于穩(wěn)定3-4部分破壞相對不穩(wěn)5-6部分破壞絕對不穩(wěn)

Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經常用24ESCC：Bilsky評分ESCC評分是用來詳細描述硬膜或脊髓受壓的程度。0級：指病變局限于骨內，無椎管內受累；1級：硬膜受壓，脊髓未受壓；2級：脊髓受壓但仍可見腦脊液信號(MRI軸位T2加權圖像)；3級：脊髓受壓并且腦脊液信號中斷。ESCC：Bilsky評分ESCC評分是用來詳細描述硬膜或脊25ESCC：Bilsky評分ESCC：Bilsky評分26OncologicalparametersOncologicalparameters27脊柱轉移性疾病課件28其他常見評分體系及分類Tomita評分（2009年）：基于預后分析改良Tokuhashi評分（2005年），Karnofsky評分Harrington評分：基于脊柱穩(wěn)定性及神經功能脊柱腫瘤不穩(wěn)定評分（SINS）Weinstein-Boriani-Biagini(WBB)分期：基于局部解剖結構Enneking分期Tomita分型其他常見評分體系及分類Tomita評分（2009年）：基于預29Harrington評分Harrington評分30Harrington評分Harrington早于1986年就根據(jù)脊柱穩(wěn)定性破壞程度和神經功能狀況對脊柱轉移性腫瘤進行分類。哈林頓認為，1，2和3期應進行保守治療，4或5期需要手術干預。3期的患者當神經系統(tǒng)可能進一步退化或癱瘓無改善的情況下，有時需接受手術治療。因此，骨受累是評估手術指征的一個重要因素。該分類過于強調內科治療的作用，對于放、化療不敏感腫瘤，外科治療的重要性并未突出，且分類過于簡單，同一類別的患者預后可能存在極大差異，缺少臨床指導意義，因此目前已很少使用。Harrington評分Harrington早于1986年就31Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉移性腫瘤進行分類，以指導手術方案選擇。1-3型廣泛切除或至少邊緣切除，4-6型只有病灶周圍存在纖維反應帶時才能邊緣切除。全脊柱整塊切除手術適用于2-5型，1、6相對適應癥，7禁忌癥。

Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉移性腫瘤進行分類，32WBB分期1997年意大利的Boriani等人提出了胸腰椎的WBB脊柱腫瘤外科分期最初針對脊柱原發(fā)性腫瘤而創(chuàng)立，但目前亦應用于脊柱轉移性腫瘤。該分期以脊髓為中心，按類似鐘表表盤布局將椎體橫斷面分為12區(qū)，并根據(jù)解剖層次以硬膜囊及骨結構為邊界將椎體及椎旁組織分為A~E層。WBB分期可清晰地顯示腫瘤侵襲范圍及脊髓壓迫程度，為手術方案制定提供重要依據(jù)。WBB分期1997年意大利的Boriani等人提出了胸腰椎的33Radiotherapy

Theprincipaltreatmentofpatientswithspinalmetastasesisradiotherapy.Thetwoprimaryreasonsthatradiotherapyisgiventopatientswithspinalmetastasesarepaincontrolanddurablelocalcontroltoimproveorpreventneurologicalcompromise.Dependingontheintentoftreatmentandothercase-specificcircumstances,radiotherapycanbedeliveredasconventionalEBRT,spineSRS,orSBRT.SpinalmetastasesaremostoftentreatedwithconventionalEBRT.TheprimarygoalofconventionalEBRTistoalleviatepain,andapproximately60–70%ofpatientshaveapartialorcompleteresponsewiththistechnique.AfterconventionalEBRT,about25%ofpatientsreportcompleteresolutioninpain,typicallyforadurationof3–4months,dependingonhistology.RadiotherapyTheprincipaltre34SBRTvsEBRTSBRTvsEBRT35surgeryThegoalofsurgeryistostabilizeamechanicallyunstablespine,decompressspinalcordcompression,removeepiduraldiseasetoallowspineSRSandSBRTtreatment,establishahistologicaldiagnosis,andtoprovidelocalcontrolwhenradiotherapycannotbesafelydelivered.Surgeryalonewillnoteradicatethediseasewithdurablelocalcontrol.Inoneneurosurgicalcaseseries,thelocalrecurrenceratewas96%at4yearsandtherewasnodifferenceinoverallsurvivalbetweenthosewhoreceivedcompleteversusincompletesurgicalresections.TheintegrationofspineSRSintothestandardtreatmentprocessrepresentsaparadigmshiftfromtheyearswhenextensivesurgeriesforgross-totalresectionswereperformedinanattempttocurepatientsofmetastaticdisease.Wedonotrecommenden-blocresectionsinthepalliationofpatientswithspinalmetastases.surgeryThegoalofsurgeryis36surgeryStabilizationwithoutdecompressioncanbeaccomplishedwithexternalbracingorminimallyinvasiveapproaches,suchaspercutaneouscementaugmentationorpercutaneouspediclescrewfixation.Theseprocedureslimittheinterruptionofsystemictherapyandallowforthedeliveryofearlyradiotherapy.surgeryStabilizationwithoutd37surgeryDebulkingEnblocPalliativedecopressionsurgeryDebulki38separationsurgeryThetermseparationsurgerywascoinedbyLilyanaAngelovandEdwardBenzelatTheClevelandClinic,OH,USA,todesignateaprocedureinwhichtumourresectionislimitedtodecompressionofthespinalcordtocreateagaptothetumourandprovideasafetargetforspineSRS.Suchatechniquehelpstofacilitatethedeliveryofanablativedosetotheresidualtumourwhilesparingthespinalcordorcaudaequina.LauferI,RubinDG,LisE,etal.TheNOMSframework:approachtothetreatmentofspinalmetastatictumors.Oncologist2013;18:744–51.LauferI,lorgulescuJB,chapmanT,etal.Localdiseasecontrolforspinalmetastasesfollowing“separationsurgery”andadjuvanthypofractionatedorhigh-dozesingle-fractionstereotacticradiosurgery:outcomeanalysisin186patients.JournalofneurosurgerySpine,2013,;18(3):207-14.separationsurgeryThetermsep39脊柱轉移性疾病課件40separationsurgeryTheessentialelementsofmostseparationsurgeriesincludeposterolateraldecompressionviaalaminectomyandpedicleresection,withapartialcorpectomyoftheaffectedlevel.Thissurgerywilldestabilisethespine;thus,astabilisationprocedureisalwaysrequiredinconjunctionwiththetumourresection.DonnellyDJ,Abd-El-BarrMM,LuY.Minimallyinvasivemusclesparingposterior-onlyapproachforlumbarcircumferentialdecompressionandstabilizationtotreatspinemetastasis—technicalreport.WorldNeurosurg2015;84:1484–90.separationsurgeryTheessentia41脊柱轉移性疾病課件42NeurointerventionalproceduresCT-guidedbiopsySpinalmyelography(commonlyusedinpatientswhohavecontraindicationstoundergoingMRIofthespine)Localablativetechniques(mostcommonlyusedasasalvagetreatmentoptionincaseswherepreviousradiotherapyhasbeendeliveredandre-irradiationisunlikelytobesafeoreffective)Cementordeviceaugmentationofthespinalcolumn(Thecementused(ie,polymethylmethacrylate)createsanexothermicreactionthatdestroystumourandnerveendingswithina3-mmradiusofthecement)Intra-arterialtumourembolisation(Preoperativetransarterialembolisationofahyper-vascularvertebraltumourwithparticles,glue,orethylenevinylalcoholcanreduceintraoperativebloodloss)WallaceAN,RobinsonCG,MeyerJ,etal.TheMetastaticSpineDiseaseMultidisciplinaryWorkingGroupalgorithms.Oncologist2015;20:1205–15.Neurointerventionalprocedures43CancerrehabilitationmanagementRehabilitationinterventionscanprovidesubstantialpainreliefandimprovestabilisationofthespinewithlessinvasivenessandinherentrisktothepatientthansurgeryorradiotherapy.Forpatientswithanunstableorpotentiallyunstablespine,surgeryisoftenwarranted.However,forpatientswhohavecontraindicationstosafelyundergosurgery,orpatientswhowishtoavoidasurgicalintervention,rehabilitationprovidestwomainoptionsforspinalstabilisation:bracingandmuscularstrengthening.Foradetaileddiscussionoftheinterventionsarehabilitationteamcanprovide,werecommendRajandLofton’sreview.RajVS,LoftonL.Rehabilitationandtreatmentofspinalcordtumors.JSpinalCordMed2013;36:4–11.Cancerrehabilitationmanageme44medicationPainmedicationsareusuallyprescribedinaladderapproach:Startingwithnon-opioidagents(ie,non-steroidalanti-inflammatorydrugsandparacetamol).Formild-to-moderatebreakthroughpain,opioidssuchascodeineandtramadolarerecommended.Forseverebreakthroughpain,opioidssuchasmorphine,oxycodone,hydromorphone,andtransdermalfentanylshouldbestarted,slowlytitrated,androtatedtoensureadequateanalgesia,whileminimisingtheriskforoverdose.Adjuvantsareaddeddependingonthetypeofpain;forexample,gabapentinorpregabalinforneuropathicpain,steroidsforinflammatorypain,andbisphosphonatesforbonepain.WHO.Cancerpainrelief:withaguidetoopioidavailability.Geneva,Switzerland,1996./iris/bitstream/10665/37896/1/9241544821.pdf(accessedFeb1,2017).medicationPainmedicationsare45Take

homemessageLifeexpectancy>2months,KPSscore>40Tomitascore,reversedTokuhashiscoreSINSsystemThegoalofsurgery:tostabilizeamechanicallyunstablespine,decompressspinalcordcompressionSeparationsurgery+SRSMDTTakehomemessageLifeexpectan46常見評分體系

的參考文獻常見評分體系

的參考文獻47Thankyou

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homemessage局部叩擊痛、夜間痛、家族史，既往史，應警惕脊柱轉移性腫瘤可能目前一般認為患者生存期>6周才有可能從穩(wěn)定手術中獲益，生存期>6個月的患者才考慮行脊柱腫瘤切除術。伴有背痛的MBD患者可能即將會發(fā)生MSCC而緩慢進展的癱瘓，數(shù)小時內發(fā)生的完全癱瘓和只有骨塊壓迫的MSCC患者是最有可能從手術中獲益的人群。（肖建如）如果脊柱是穩(wěn)定的(SINS0-6分)，脊柱腫瘤沒有引起神經受壓，多學科協(xié)作討論后，根據(jù)腫瘤具體類型(例如乳腺癌、前列腺癌等放化療敏感的腫瘤)可以先行放療或化療，以控制或減緩腫瘤進展。脊柱轉移性腫瘤的診斷也須遵循臨床、影像和病理三結合的原則。Takehomemessage局部叩擊痛、夜間痛、家族史49Take

homemessage對于偶然發(fā)現(xiàn)、無明顯癥狀的孤立性脊柱轉移瘤，應先行放療，如腫瘤增長較快，預計短期會發(fā)生病理骨折者，為避免脊髓在病理骨折時發(fā)生嚴重損傷，多建議手術治療。多發(fā)脊柱轉移瘤并非手術禁忌，筆者的經驗是對引起神經癥狀的轉移灶進行外科干預可取得較好的療效。目前認為患者完全癱瘓大于48h術后恢復神經功能的可能性較低，是手術的相對禁忌證。預期生存期小于3個月的患者無法從手術中獲益，是手術的禁忌證。術前放射治療增加手術傷口不愈合的風險，而且這種風險與術前放療的劑量和頻次無關,已不再提倡。開放性手術一般于術后2~3周待傷口愈合后再進行放射治療，而對于微創(chuàng)手術術后患者可立即接受放療。Takehomemessage對于偶然發(fā)現(xiàn)、無明顯癥狀的50metastaticspinedisease:EvolutionXUWENBINSIRRUNRUNSHAWHOSPITALmetastaticspinedisease:Evol51backgroundIntheUSA,nearly300000adultshaveosseousmetastaticdisease,withapproximately60%ofthemetastasesbeingspinalmetastases.Approximately10%ofpatientswithspinalmetastasesdevelopspinalcordcompression—asevereandoftenpermanentlydisablingconditionthatisanoncologicalemergency.Historically,spinalmetastaseshavebeentreatedwithinvasivesurgicalapproaches(eg,en-blocresection),orlow-dosepalliativeconventionalexternal-beamradiotherapy(EBRT),orboth.backgroundIntheUSA,nearly352脊柱轉移性疾病課件53backgroundEvolutionofsurgerycanbetracedfrominappropriateopensurgery(i.e.laminectomy)toappropriateopen(i.e.posteriorinstrumentationanddecompression)andfurthertominimallyinvasivesurgery.Presently,thebestclinicaloutcomesareachievedbysurgerywithtimelypostoperativeradiotherapy.

spinestereotacticbodyradiotherapy(SBRT),spinestereotacticradiosurgery(SRS)backgroundEvolutionofsurgery54Primarysite乳腺22%肺15%前列腺10%黑色素瘤9%淋巴瘤7%胃腸道5%腎臟6%甲狀腺3%男性：肺癌，前列腺癌，腎癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宮癌、甲狀腺癌、結腸癌、胃癌。Primarysite乳腺22%男性：肺癌，前列腺癌，腎癌55Lifeexpectancy肺癌：術后4月結腸癌：7月腎癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲狀腺癌：10年（80-95%）1年：48%5年：1.5%Lifeexpectancy肺癌：術后4月1年：48%56InvolvedsegmentAutopsystudieshavedemonstratedthelumbarspinetobemostcommonlyinvolved,followedbythethoracicandcervicalsegments.Clinically,symptomaticspinalmetastasesaremostoftenlocalizedtothethoracicspine(withspecialpredilectionforthesegmentsaboutT4andT11),followedbythelumbarandcervicalsegments.Thoracic70%Lumbar20%Cervical10%InvolvedsegmentAutopsystudie57metastasispathwayHematogenousmetastasis：Batson’svenousplexus，cancerembolusLymphaticmetastasisImplantationmetastasisCSFmetastasismetastasispathwayHematogenous58Clinicalmanifestation疼痛是最常見的癥狀，約有70%患者以疼痛起病。疼痛常逐漸變?yōu)槌掷m(xù)性加劇，夜間痛明顯，制動多無效。嚴重者止痛藥無效。大約有50%的胸脊髓損害患者在脊髓壓迫癥狀出現(xiàn)時即表現(xiàn)出神經根性疼痛。疼痛因病癥部位不同而異。

由于轉移瘤主要位于椎體，往往從前方壓迫椎體束或前角細胞，故運動功能損害常先出現(xiàn)。與其他脊髓病損類似，括約肌功能損害常提示不良預后。以脊柱轉移為首發(fā)癥狀的為10%。Clinicalmanifestation疼痛是最常見的癥59RadiologicalexamX線平片是脊柱轉移瘤診斷最基本的影像學檢查方法，常表現(xiàn)為骨質疏松、溶骨性或硬化性改變，以椎弓根消失（貓頭鷹眨眼征）、椎體塌陷較常見，椎間隙通常正常。博蘭（Boland）等認為椎體的扁平壓縮比楔形變更有意義。相比X線平片，核素全身骨掃描可提前3~6個月發(fā)現(xiàn)骨性損害，其靈敏度高達95%~97%,多表現(xiàn)為放射性濃聚，對可疑骨轉移瘤患者應盡量作骨掃描檢查。對于椎體破壞及椎旁、椎管內占位性病變，應用CT檢查顯示較清楚，但當病變較小、CT掃描層距較寬時，容易漏診。對于軟組織病變檢查，MRI可提供比X線平片、同位素、CT等檢查更精確的影像學信息。對于選擇治療方法、手術進路等都具有重要的實用價值。

RadiologicalexamX線平片是脊柱轉移瘤診斷60脊柱轉移性疾病課件61脊柱轉移性疾病課件62questionsGlobalperformancestatus?Lifeexpectancy?Mechanicalstableorunstable?Surgery,radiotherapy,orchemotherapy?Whensurgery?Radiotherapybeforeorafterthesurgery?Howlong?Medicinechoose,Steroidetc?questionsGlobalperformancest63脊柱轉移性疾病課件64脊柱轉移性疾病課件65KPS評分References:

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Crooks,V,Wa66ToMITa評分Tomita等對67例脊柱轉移性腫瘤患者進行回顧性分析并總結制定新的預后評分系統(tǒng)，根據(jù)腫瘤惡性程度、臟器轉移及骨轉移情況進行評價，總分2~10分，根據(jù)不同評分指導選擇不同治療方案。前瞻性研究顯示其預期生存時間和實際生存時間符合率為84%。注重預后，沒有把神經壓迫考慮進去。

ToMITa評分Tomita等對67例脊柱轉移性腫瘤患者進行67Tomita評分Tomita評分68修正的Tokuhashi評分提示平均生存時間Zou等研究認為，修正的Tokuhashi評分系統(tǒng)對于短期預后的判斷較為準確，而Tomita評分系統(tǒng)則更適用于長期預后結果的推測。ZouXN,GrejsA,LiHS,etal.Estimationoflifeexpectancyforselectingsurgicalprocedureandpredictingprognosisofextraduralspinalmetastases[J].AiZheng，2006，25(11):1406—1410.修正的Tokuhashi評分提示平均生存時間ZouXN,69脊柱轉移性疾病課件70脊柱轉移性疾病課件71脊柱轉移性疾病課件72SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對SINS系統(tǒng)進行可信度及有效性分析，認為其預測準確性較好，靈敏度和特異度分別為95.7和79.52%。但SINS系統(tǒng)僅針對病灶局部穩(wěn)定性進行評價，并未考慮患者全身情況，僅能用于制定局部治療方案，無法對患者預后進行評估。SINS系統(tǒng)：穩(wěn)定性評估世界脊柱腫瘤研究小組（GSTSG）對73Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經常用于評價脊柱的穩(wěn)定性。kostuik分脊椎成六柱，包括椎體十字分割的四柱，和后部的兩柱，并提出腫瘤占三柱或更多時會出現(xiàn)脊柱不穩(wěn)，而當腫瘤累及五個或更多柱時，脊柱不穩(wěn)更加嚴重。他還提出，椎體塌陷角為20°或更大時為脊柱不穩(wěn)。這種分類是一種有用的準則，但也并非適用任何情況，因為有時腫瘤可能侵犯三或更多的部分，而不引起癥狀。1-2部分破壞屬于穩(wěn)定3-4部分破壞相對不穩(wěn)5-6部分破壞絕對不穩(wěn)

Kostuik六柱理論：穩(wěn)定性Kostuik的六柱理論經常用74ESCC：Bilsky評分ESCC評分是用來詳細描述硬膜或脊髓受壓的程度。0級：指病變局限于骨內，無椎管內受累；1級：硬膜受壓，脊髓未受壓；2級：脊髓受壓但仍可見腦脊液信號(MRI軸位T2加權圖像)；3級：脊髓受壓并且腦脊液信號中斷。ESCC：Bilsky評分ESCC評分是用來詳細描述硬膜或脊75ESCC：Bilsky評分ESCC：Bilsky評分76OncologicalparametersOncologicalparameters77脊柱轉移性疾病課件78其他常見評分體系及分類Tomita評分（2009年）：基于預后分析改良Tokuhashi評分（2005年），Karnofsky評分Harrington評分：基于脊柱穩(wěn)定性及神經功能脊柱腫瘤不穩(wěn)定評分（SINS）Weinstein-Boriani-Biagini(WBB)分期：基于局部解剖結構Enneking分期Tomita分型其他常見評分體系及分類Tomita評分（2009年）：基于預79Harrington評分Harrington評分80Harrington評分Harrington早于1986年就根據(jù)脊柱穩(wěn)定性破壞程度和神經功能狀況對脊柱轉移性腫瘤進行分類。哈林頓認為，1，2和3期應進行保守治療，4或5期需要手術干預。3期的患者當神經系統(tǒng)可能進一步退化或癱瘓無改善的情況下，有時需接受手術治療。因此，骨受累是評估手術指征的一個重要因素。該分類過于強調內科治療的作用，對于放、化療不敏感腫瘤，外科治療的重要性并未突出，且分類過于簡單，同一類別的患者預后可能存在極大差異，缺少臨床指導意義，因此目前已很少使用。Harrington評分Harrington早于1986年就81Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉移性腫瘤進行分類，以指導手術方案選擇。1-3型廣泛切除或至少邊緣切除，4-6型只有病灶周圍存在纖維反應帶時才能邊緣切除。全脊柱整塊切除手術適用于2-5型，1、6相對適應癥，7禁忌癥。

Tomita分型根據(jù)腫瘤侵襲范圍對脊柱轉移性腫瘤進行分類，82WBB分期1997年意大利的Boriani等人提出了胸腰椎的WBB脊柱腫瘤外科分期最初針對脊柱原發(fā)性腫瘤而創(chuàng)立，但目前亦應用于脊柱轉移性腫瘤。該分期以脊髓為中心，按類似鐘表表盤布局將椎體橫斷面分為12區(qū)，并根據(jù)解剖層次以硬膜囊及骨結構為邊界將椎體及椎旁組織分為A~E層。WBB分期可清晰地顯示腫瘤侵襲范圍及脊髓壓迫程度，為手術方案制定提供重要依據(jù)。WBB分期1997年意大利的Boriani等人提出了胸腰椎的83Radiotherapy

Theprincipaltreatmentofpatientswithspinalmetastasesisradiotherapy.Thetwoprimaryreasonsthatradiotherapyisgiventopatientswithspinalmetastasesarepaincontrolanddurablelocalcontroltoimproveorpreventneurologicalcompromise.Dependingontheintentoftreatmentandothercase-specificcircumstances,radiotherapycanbedeliveredasconventionalEBRT,spineSRS,orSBRT.SpinalmetastasesaremostoftentreatedwithconventionalEBRT.TheprimarygoalofconventionalEBRTistoalleviatepain,andapproximately60–70%ofpatientshaveapartialorcompleteresponsewiththistechnique.AfterconventionalEBRT,about25%ofpatientsreportcompleteresolutioninpain,typicallyforadurationof3–4months,dependingonhistology.RadiotherapyTheprincipaltre84SBRTvsEBRTSBRTvsEBRT85surgeryThegoalofsurgeryistostabilizeamechanicallyunstablespine,decompressspinalcordcompression,removeepiduraldiseasetoallowspineSRSandSBRTtreatment,establishahistologicaldiagnosis,andtoprovidelocalcontrolwhenradiotherapycannotbesafelydelivered.Surgeryalonewillnoteradicatethediseasewithdurablelocalcontrol.Inoneneurosurgicalcaseseries,thelocalrecurrenceratewas96%at4yearsandtherewasnodifferenceinoverallsurvivalbetweenthosewhoreceivedcompleteversusincompletesurgicalresections.TheintegrationofspineSRSintothestandardtreatmentprocessrepresentsaparadigmshiftfromtheyearswhenextensivesurgeriesforgross-totalresectionswereperformedinanattempttocurepatientsofmetastaticdisease.Wedonotrecommenden-blocresectionsinthepalliationofpatientswithspinalmetastases.surgeryThegoalofsurgeryis86surgeryStabilizationwithoutdecompressioncanbeaccomplishedwithexternalbracingorminimallyinvasiveapproaches,suchaspercutaneouscementaugmentationorpercutaneouspediclescrewfixation.Theseprocedureslimittheinterruptionofsystemictherapyandallowforthedeliveryofearlyradiotherapy.surgeryStabilizationwithoutd87surgeryDebulkingEnblocPalliativedecopressionsurgeryDebulki88separationsurgeryThetermseparationsurgerywascoinedbyLilyanaAngelovandEdwardBenzelatTheClevelandClinic,OH,USA,todesignateaprocedureinwhichtumourresectionislimitedtodecompressionofthespinalcordtocreateagaptothetumourandprovideasafetargetforspineSRS.Suchatechniquehelpstofacilitatethedeliveryofanablativedosetotheresidualtumourwhilesparingthespinalcordorcaudaequina.LauferI,RubinDG,LisE,etal.TheNOMSframework:approachtothetreatmentofspinalmetastatictumors.Oncologist2013;18:744–51.LauferI,lorgulescuJB,chapmanT,etal.Localdiseasecontrolforspinalmetastasesfollowing“separationsurgery”andadjuvanthypofractionatedorhigh-dozesingle-fractionstereotacticradiosurgery:outcomeanalysisin186patients.JournalofneurosurgerySpine,2013,;18(3):207-14.separationsurgeryThetermsep89脊柱轉移性疾病課件90separationsurgeryTheessentialelementsofmostseparationsurgeriesincludeposterolateraldecompressionviaalaminectomyandpedicleresection,withapartialcorpectomyoftheaffectedlevel.Thissurgerywilldestabilisethespine;thus,astabilisationprocedureisalwaysrequiredinconjunctionwiththetumourresection.DonnellyDJ,Abd-El-BarrMM,LuY.Minimallyinvasivemusclesparingposterior-onlyapproachforlumbarcircumferentialdecompressionandstabilizationtotreatspinemetastasis—technicalreport.WorldNeurosurg2015;84:1484–90.separationsurgeryTheessentia91脊柱轉移性疾病課件92NeurointerventionalproceduresCT-guidedbiopsySpinalmyelography(commonlyusedinpatientswhohavecontraindicationstoundergoingMRIofthespine)Localablativetechniques(mostcommonlyusedasasalvagetreatmentoptionincaseswherepreviousradiotherapyhasbeendeliveredandre-irradiationisunlikelytobesafeoreffective)Cementordeviceaugmentationofthespinalcolumn(Thecementused(ie,polymethylmethacrylate)createsanexothermicreactionthatdestroystumourandnerveendingswithina3-mmradiusofthecement)Intra-arterialtumourembolisation(Preoperativetransarterialembolisationofahyper-vascularvertebraltumourwithparticles,glue,orethylenevinylalcoholcanreduceintraoperativebloodloss)WallaceAN,RobinsonCG,MeyerJ,etal.TheMetastaticSpineDiseaseMultidisciplinaryWorkingGroupalgorithms.Oncologist2015;20:1205–15.Neurointerventionalprocedures93CancerrehabilitationmanagementRehabilitationinterventio