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A Comparison of Two Short Education Programs for Improving Low Back Pain-Related Disability in the Elderly: A Cluster Randomized Controlled Trial.

Randomized Trial

Spine. 32(10):1053-1059, May 1, 2007.
Kovacs, Francisco MD, PhD *; Abraira, Victor PhD +; Santos, Severo MD ++; Diaz, Elena MSc +; Gestoso, Mario MD *; Muriel, Alfonso MSc +; Gil del Real, Maria Teresa MPH *; Mufraggi, Nicole MD *; Noguera, Juan MD [S]; Zamora, Javier PhD +; for the Spanish Back Pain Research Network
Abstract:
Study Design. Cluster randomized clinical trial.

Objectives. To assess the effectiveness of 2 minimal education programs for improving low back pain (LBP)-related disability in the elderly.

Summary of Background Data. No education program has shown effectiveness on low back pain (LBP)-related disability in the elderly.

Methods. A total of 129 nursing homes (6389 residents) in northern Spain were invited to participate in the study. The actual participants were 12 nursing homes randomly assigned to 3 groups and 661 subjects. An independent physician gave a 20-minute talk with slide projections summarizing the content of the Back Book (active management group), the Back Guide (postural hygiene group), and a pamphlet on cardiovascular health (controls). Disability was measured with the Roland-Morris questionnaire (RMQ). Blind assessments were performed before the intervention, and 30 and 180 days later. The effect of the intervention on disability was estimated by generalized mixed linear random effects models.

Results. Mean age of participants ranged between 79.9 and 81.2 years. Disability improved in all groups, but at the 30-day assessment the postural education group showed an additional improvement of 1.1 (95% confidence interval, 0.2-1.9), RMQ points and at the 180-day assessment the active education group an additional improvement of 2.0 (95% confidence interval, 0.6-3.4). In the subset of subjects with LBP when entering the study, postural education had no advantages over controls, while an additional improvement of 3.0 (95% confidence interval, 1.5- 4.5) RMQ points at the 180-day assessment was observed in the active education group.

Conclusion. In institutionalized elderly, the handing out of the Back Book supported by a 20-minute group talk improves disability 6 months later, and is even more effective in those subjects with LBP.
两种短期教育在改善老年人腰背痛相关性功能障碍的比较
设计:群体性随机临床试验
目的:评价比较两种短期教育计划在改善老年人下腰痛相关性功能障碍的作用。
背景:目前,没有一种短期健康教育在下腰痛相关性残疾中有效。
方法:在西班牙北部共有129个护理家庭(6389个居民)被邀请参与这个研究计划。实际参与者为12个护理家庭,被分到3个组中,共计661位患者。让一个不知情独立医生给予讲解20分钟的幻灯片总结《背部》(积极治疗组);讲解姿势疗法《背部指南》(姿势疗法组);对照组予以发一本心血管健康小册子。下腰痛的残疾指数采用Roland-Morris问卷调查。分别于介入前,及介入后30天,180天测量。干涉效果评估采用纵向数据混合效应模型。
结果:参与者的平均年龄在79.9-81.2岁之间。功能障碍各组均有所改善,但是在30天的测试中姿势组教育组RMQ分数额外改善1.1分(95%可信区间,0.2-1.9),在180天测试积极活动组RMQ分数额外改善2.0分(95%可信区间,0.6-3.4)。在进入这项研究的下腰痛患者中,姿势教育不好于对照组,而积极活动教育组在180天RMQ问卷调查评估改善3分(95%可信区间,1.5-4.5)。
结论:在老年人的健康教育中,通过20分钟的健康讨论背部书籍,可以改善下腰痛性功能障碍,特别是对患有下腰痛的患者。

Selective Vulnerability to Ischemia in the Rat Spinal Cord: A Comparison Between Ventral and Dorsal Horn Neurons.

Basic Science

Spine. 32(10):1060-1066, May 1, 2007.
Nohda, Kazuhiro MD *; Nakatsuka, Terumasa MD, PhD +; Takeda, Daisuke BS *; Miyazaki, Nobuyuki MD *; Nishi, Hideto MD *; Sonobe, Hideki MD, PhD *; Yoshida, Munehito MD, PhD *
Abstract:
Study Design. Whole-cell patch-clamp recordings were performed from ventral horn (VH) and dorsal horn (DH) neurons obtained from the rat spinal cord slices.

Objective. This study investigated which is more vulnerable to ischemia, spinal VH neurons or DH neurons.

Summary of Background Data. Spinal cord ischemia or injury sometimes causes a greater loss of motor function than of sensory function in patients. However, it is difficult to evaluate whether spinal motor neurons are more vulnerable than sensory neurons because of the anatomic complexity and a variety of physiologic factors in the spinal cord.

Methods. Whole-cell patch-clamp recordings were performed from VH and DH neurons obtained from the spinal cord slices. Ischemia was simulated by superfusing an oxygen- and glucose-deprived medium (ischemia simulating medium [ISM]).

Results. Perfusion with ISM generated an agonal depolarization in all VH and DH neurons recorded in current-clamp mode. Following ISM superfusion, an agonal inward current was produced at a holding potential of -70 mV in all VH and DH neurons tested in voltage-clamp mode. The agonal inward current consisted of a slow and subsequent rapid inward current. The average latency of the rapid inward currents after ISM exposures in VH neurons was significantly shorter than that in DH neurons. The average amplitude of the agonal inward currents in VH neurons was significantly bigger than that of DH neurons. Moreover, the recovery ratio by the reintroduction of oxygen and glucose in VH neurons was smaller than that in DH neurons.

Conclusions. These results suggest that VH neurons are more vulnerable to ischemia than DH neurons. This finding may help in achieving a better understanding of the difference between motor and sensory disturbance in spinal cord ischemia or injury patients
鼠脊髓腹侧神经元与背侧神经元对缺血性损伤变化的比较

设计:利用全细胞膜电位记录从大鼠脊髓中腹侧和背侧神经元对缺血变化。
目的:本研究主要目的是探讨脊髓腹侧神经元还是背侧神经元对缺血更易损伤。
背景:脊髓缺血或外伤常常导致运动功能的丧失大于感觉。然而,由于解剖结构的复杂性和脊髓多种生理因素的参与,很难判断脊髓运动神经元比感觉神经元更容易受到损伤。
方法:分别从脊髓腹侧和背侧获取神经元组织,将其置于全细胞膜片箝中。并将其置于去除氧气和葡萄糖的培养基中观察来模拟缺血损伤(模拟缺血培养基)。
结果:所有腹侧和背侧神经元在电流箝记录中均出现濒死的去极化改变。在电位箝模式中所有神经元在域电位-70mv时可见电流内流现象。濒死的内向电流包括慢速和后来的快速内向电流。缺血后腹侧神经元的快速内向电流平均潜伏期比背侧神经元明显缩短。电流的平均幅度腹侧神经元比背侧神经元明显要大。此外,予以输注氧气和葡萄糖后,腹侧神经元复苏比背侧明显减少。
结论:这个结果说明大鼠脊髓腹侧神经元比背侧神经元对缺血反应更易损伤。这项发现有助于理解脊髓损伤后运动和感觉功能的不同恢复情况。

4. Mechanical Comparison of Posterior Instrumentation Constructs for Spinal Fixation Across the Cervicothoracic Junction
跨越颈胸段的脊柱后路固定装置的力学比较


Degenerative, traumatic, tumor and infectious disease processes sometimes require surgical stabilization and fusion across the cervicothoracic junction. Depending on the clinical situation, the goals of such surgery may include spinal cord or nerve root decompression, restoration of sagittal alignment, and avoidance of complications such as pseudarthrosis, anterior graft dislodgement, and adjacent segmental degenerative disease.
退变、创伤、肿瘤以及感染等疾病常需要跨越颈胸段进行外科稳定和融合。跟据临床情况,这些手术的目的可能包括脊髓或神经根减压、矢状面排列的恢复和避免并发症,如假关节形成、前方植骨块的脱出和临近节段的退行性疾病。
Posterior screw-and-rod-based instrumented systems have been shown to provide greater biomechanical stability than anterior constructs by taking advantage of the stronger fixation offered by the lateral masses or pedicles, as well as the greater distance of the fixation from the midsagittal plane. Posterior instrumentation has been recommended as a complement to anterior fusion across more than 3 disc levels as a means of reducing the incidence of anterior graft dislodgement and nonunion.
后路钉棒装置系统与前路装置相比,由于使用了牢固的侧块螺钉或椎弓根螺钉,以及在正中矢状面上有更长的固定距离,因此可以提供更好的生物力学稳定性。当经前路融合超过3个节段时,推荐进行后路固定以减少前路植骨块脱出与不连接的发生风险。
The cervicothoracic junction is a transitional area where the cervical spine lateral masses decrease in size and the vertebral pedicles increase in size within the thoracic region. As a result, cervical lateral mass screws are generally smaller in length and diameter with starting points, which are medially aligned relative to thoracic pedicle screws.
颈胸段是颈椎侧块减小向胸椎椎弓根增大的过渡区域。因此,颈椎侧块螺钉与胸椎椎弓根螺钉相比,长度和直径较小,进钉点要更向中间靠近。
Several instrumentation systems are available for posterior spinal stabilization across the cervicothoracic junction. One option is to extend cervical implants into the upper thoracic vertebrae. Dual diameter rods offer a solid connection between smaller cervical screws and larger thoracic screws. Finally, 2 rods of differing diameters can be connected to each other by means of various cross connectors. To date, the comparative mechanical properties of these constructs have not been reported.
有数种装置系统可供选择用于后路跨越颈胸段脊柱的稳定。其中的一种选择是将颈椎植入装置延伸至胸椎上。双直径棒可以将较小的颈椎螺钉与较大的胸椎螺钉进行坚强的连接。而2根不同直径的棒也可以通过不同的连接器进行连接。至今为止,尚未见这些装置之间的力学性质的比较方面的文献报道。
This study describes mechanical testing of 4 implant constructs designed for fixation across the cervicothoracic junction. Our hypothesis was that the various constructs available for posterior cervicothoracic fixation would be mechanically equivalent.
本研究描述了4种用于跨颈胸段固定的植入装置的力学实验。我们假设用于后路颈椎固定的不同的装置在力学方面是等同的。
Materials and Methods
材料与方法
All screws were implanted into 2 ultra-high molecular weight polyethylene (UHMWPE) blocks; 1 UHMWPE block simulated the cervical connection and 1 simulated the thoracic connection. Screws were spaced within the corresponding UHMWPE blocks according to the interfacet distances reported by An et al.
所有的螺钉都植入2个超高分子量聚乙烯(UHMWPE)块中。其中1个UHMWPE块模仿颈连接部,另1个模仿胸连接部。在UHMWPE块中螺钉之间排列的依据是An等报告的小关节之间的距离。
The first construct consisted of 3 paired 3.5-mm diameter, 14-mm length, lateral mass screws in the cervical block and 2 paired 3.5-mm diameter, 18-mm length, pedicle screws in the thoracic block connected via a 3.5-mm diameter rod. The remaining 3 constructs all used 3 paired 3.5-mm by 14-mm screws in the cervical block and 2 paired 5.0-mm by 18-mm screws in the thoracic block. The second construct connected the cervical and thoracic blocks via 3.5-/5.5-mm dual diameter rods. The third construct connected the cervical and thoracic blocks with 3.5-mm cervical and 5.5-mm thoracic rods connected via a solid domino connector. The final construct connected the cervical and thoracic blocks with 3.5-mm and 5.5-mm diameter rods connected via a uniplanar hinged domino connector (Figure 1). All implants were from the Mountaineer and Expedium systems (Depuy Spine, Raynham, MA).
第一种装置包括颈部UHMWPE块的3对直径3.5mm、长14mm的侧块螺钉,和胸部UHMWPE块的2对直径3.5mm、长18mm的椎弓根螺钉,螺钉之间以直径3.5mm的棒相连。其余的3种装置都使用了3对直径3.5mm、长14mm的螺钉在颈部UHMWPE块,以及2对5.0mm×18mm的螺钉在胸部UHMWPE块。第二种装置通过3.5-/5.5-mm的双直径棒连接颈胸部;第三种在颈部块和胸部块上分别安装直径3.5mm棒和5.5mm棒,两棒之间通过坚强domino连接器相连;最后一种装置同样在颈部块和胸部块上分别安装直径3.5mm棒和5.5mm棒,但两棒之间使用单平面铰链domino连接器相连(Figure 1)。所有装置均为Mountaineer and Expedium系统(Depuy Spine, Raynham, MA)。
The cervical blocks were connected via hinge pins, which allowed rotation in the sagittal axis to an actuator, while the thoracic blocks were attached to a 6-degree of freedom load cell (Figure 2). Static displacement-controlled testing was performed in compression bending and axial rotation in accordance with the American Society for Testing and Materials guideline, F1717 standard Static and Dynamic Test Method for Spinal Implant Assemblies in a Corpectomy Model.
颈部块与铰链栓相连,允许在矢状面围绕一个调节器进行旋转;而胸块与一个有6个自由度的测力计相连(Figure 2)。对固定装置的压迫弯曲和轴向旋转两种运动方式进行了静力位移控制试验,试验方案参照American Society for Testing and Materials指南,F1717脊柱内植物标准静力与动力试验方法。
Five constructs of each type were tested in compression bending and 5 were tested in axial torsion. Implants were loaded to failure at a rate of 25.4 mm/min for compression bending or 30°/min for axial rotation. Failure was defined as implant fracture, compressive displacement of 30 mm of displacement, or rotational displacement of 30°. Stiffness was calculated from force versus displacement curves. Yield force was defined as the force at which the construct transitioned from elastic to plastic deformation. Maximum force was defined as the highest amount of force the construct withstood during plastic deformation. Statistical comparisons among groups were performed using an analysis of variance. Statistical significance was established at P <0.05.
所有的装置(明明是4种,不明白文章里为什么说是5种装置)均接受了压迫弯曲和轴向旋转的试验。以25.4 mm/min的速度施加压力,30°/min的速度施加轴向旋转,直至内植物毁损。毁损的定义为内植物折断、压缩位移达到30mm,或旋转角度达到30°。刚度由应力除以位移计算得到。屈服应力定义为装置从弹性变形转变为塑性变形时的应力值。最大应力定义为装置在塑性变形期间所能承受的最大的应力值。各组之间的统计学比较使用方差分析,显著性定义为P<0.05。
Results
结果
Flexion Stiffness
弯曲刚度
In flexion bending testing, construct A, or the continuous 3.5 mm rod-and-screw construct (19.3 N/mm) was significantly less stiff compared with the constructs incorporating larger diameter rods, B (37.0 N/mm, P<0.01), C (38.2 N/mm, P<0.01), or D (27.6 N/mm, P<0.01). Construct B (dual diameter rods) was not significantly different from construct C (solid domino) or D (hinged domino) (P=0.94, P=0.99, respectively). Similarly, there was also no statistically significant differences in stiffness between construct C to D (P=1.0) (Table 1, Figure 3A).
在弯曲试验中,装置A,即使用了3.5mm钉棒的装置的刚度(19.3N/mm),要明显小于其他使用较粗的棒的装置,如B(37.0mm, P<0.01), C (38.2 N/mm, P<0.01), 或 D (27.6 N/mm, P<0.01)。装置B(双直径棒)与装置C(坚固接棒器)或D(铰链接棒器)相比,刚度无显著差异(P=0.94, P=0.99)。同样的,装置C与D之间的刚度也没有显著差异(P=1.0) (Table 1, Figure 3A)。
Flexion Load to Failure
弯曲试验的极限载荷
In flexion load to failure testing, construct A had a significantly less yield force (153.6 N) when compared with construct B (220.7 N, P<0.01) or C (225.4 N, P<0.01). Additionally, construct A had a significantly less maximum force (253.5 N) when compared with construct B (315.5 N, P<0.01) or C (314.0 N, P<0.01). Construct A was not significantly different from construct D for yield force (262.0 N, P=0.4) or maximum force (P=0.89). Construct B showed no difference to construct C for yield force (P=0.97) or maximum force (P=1.00). Finally, construct D was significantly different from constructs B (P=0.01) and C (P<0.01) for yield force and for maximum force (P=0.01, P<0.01, respectively). This difference appears to reflect the catastrophic failure at the hinge of the domino connector, which occurred with construct D. In contrast, constructs A, B, and C all failed due to plastic deformation of the 3.5-mm rods (Table 1, Figure 3.
在弯曲极限载荷试验中,装置A的屈服应力(153.6N)要显著小于装置B(220.7 N, P<0.01)或C (225.4 N, P<0.01)。同样,装置A的最大应力(253.5N)也要显著小于装置B (315.5 N, P<0.01)或C (314.0 N, P<0.01)。装置A的屈服应力和最大应力与装置D的屈服应力(262.0 N, P=0.4)和最大应力(P=0.89)之间没有显著差异。装置B与C之间的屈服应力与最大应力也没有显著差异(P=0.97,P=1.00)。最后,装置B与装置C或D之间的屈服应力(P=0.01, P<0.01)和最大应力(P=0.01, P<0.01)之间存在显著差异。从装置失败的情况来看,装置D主要表现为铰链接棒器的破坏,而装置A、B、C的失败都表现为3.5mm棒的塑性变形(Table 1, Figure 3B)。
Axial Stiffness
扭转刚度
In axial rotation testing, construct A again demonstrated statistically lower torsional stiffness in comparison to construct B (1.96 Nm/°, P<0.01), C (1.85 Nm/°, P<0.01), and D (1.0 Nm/° vs. 2.0 Nm/°, P<0.01). Construct B was not statistically significant from construct C (P=0.68) or D (P=0.77). Additionally, construct C was not statistically significant from construct D (P=0.78) (Table 2, Figure 4A).
在轴向旋转试验中,装置A的扭转刚度(1.0 Nm/°)同样要显著小于装置B(1.96 Nm/°, P<0.01), C (1.85 Nm/°, P<0.01), and D (2.0 Nm/°, P<0.01)。装置B的扭转刚度与装置C、D相比无显著差异(P=0.68,P=0.77)。此外,装置C与装置D之间也没有显著差异(P=0.78)(Table 2, Figure 4A)。
Axial Rotation Load to Failure
轴向旋转试验的极限载荷
In axial rotation load to failure, construct A was significantly different than construct B and C for yield torque (14.5 Nm vs. 23.8 Nm and 22.4 Nm, P<0.01, respectively) and maximum torque (19.0 Nm vs. 32.3 Nm and 31.2 Nm, P<0.01). Construct A was not different compared with construct D for yield torque (17.6 Nm, P=0.84) but was significantly different for maximum torque (29.7 Nm, P<0.01) (Table 1). Constructs B and C were not different from each other for yield torque (P=0.77) or maximum torque (P=0.87). Construct B was significantly different from construct D for yield torque (P=0.01) but not for maximum torque (P=0.36). Finally, construct C was significantly different from construct D for both yield and maximum torques (P<0.01) (Table 2, Figure 4. P values from all testing modes are summarized in Table 3.
在轴向旋转极限载荷试验中,装置A与装置B和C的屈服转力矩(14.5 Nm vs. 23.8 Nm and 22.4 Nm, P<0.01)和最大转力矩(19.0 Nm vs. 32.3 Nm and 31.2 Nm, P<0.01)都有显著差异。装置A与D的屈服转力矩(17.6 Nm, P=0.84)没有显著差异,但是最大转力矩存在显著差异(29.7 Nm, P<0.01)(Table 1)。装置B与C之间的屈服转力矩(P=0.77)与最大转力矩(P=0.87)均没有显著差异。装置B与D之间,屈服转力矩有显著差异(P=0.01),而最大转力矩无显著差异(P=0.36)。最后,装置C与D之间,屈服转力矩和最大转力矩都存在显著差异(P<0.01)(Table 2, Figure 4。所有试验模型之间的P值见Table 3。
Discussion
讨论
This mechanical study of 4 different posterior spinal instrumentation constructs for cervicothoracic junction found statistically significant differences among several constructs with respect to stiffness, yield force, and maximum force under static displacement controlled loading. We therefore reject our hypothesis that these 4 constructs would function equivalently.
本文对用于颈胸段的4种不同的后路脊柱内固定装置进行了力学研究,发现一些装置之间在静态控制位移载荷下,其刚度、屈服应力和最大应力存在显著差别。因此,我们拒绝先前关于4种装置在功能上等同的假设。
Posterior constructs using a 3.5-mm diameter rod and 3.5-mm screws in the thoracic block were less stiff and failed at lower loads. This suggests that larger diameter thoracic screws and rods should be considered as an bxoption in clinical situations with substantial expected loading.
在胸块使用3.5mm钉棒的后路装置刚度和所能承受的载荷均较小。这表明临床上可能需要更粗的胸椎螺钉以及棒。
The hinged domino construct consistently failed at the hinge axis, which led to a lower yield force and maximum force in flexion bending and a lower yield torque in axial rotation than either the solid domino construct or the dual diameter rod. While the sagittal plane flexibility of this device is attractive from the standpoint of ease of insertion, these results suggest a structural weakness that could potentially lead to clinical failures.
铰链装置始终在铰链轴上发生失败,这使得其在弯曲试验中的屈服应力和最大应力,以及在轴向旋转试验中的屈服转力矩,都要低于使用坚固接棒器或双直径棒的装置。虽然从减少插入的观点来看这种装置的矢状面弹性具有一定的优点,但本研究的结果提示结构的弱点可能导致临床的失败。
The dual diameter rod and the fixed domino constructs were not statistically distinguishable for any tested parameters in either flexion bending or axial rotation, suggesting that either construct should function similarly. Although an argument can be made that the added bulk of the dominos may reduce space available for bone graft, we found that the domino connectors allow for easier rod contouring and implant placement, given the dual diameter rod’s tendency to bend at the transition point.
双直径棒和坚强接棒器装置在弯曲试验和轴向旋转试验的参数上均没有统计学差别,提示这两种装置在功能上可能类似。虽然有争论说使用体积较大的接棒器可能会减少植骨的空间,但我们发现使用接棒器的弯帮塑形和放置植入物相对容易,而双直径棒则更倾向于在连接部发生弯曲。
Limitations of this study include the use of a polyethylene block model, which only evaluates the mechanical properties of the spinal instrumentation, leaving out an evaluation of the implant bone interface failure. It is well documented that the implant-bone interface is frequently the site of clinical failures. Our model also removes the effects of motion between the multiple cervical and thoracic points of fixation and does not assess the clinically important failure mode of fatigue loading given the use of static displacement-controlled testing. Finally, these tests implicitly assume that increased implant stiffness and mechanical strength will result in an improvement in clinical success, which of course, is not always the case.
本研究的局限包括使用聚乙烯块模型,这只能评估脊柱装置的机械属性,却无法评估植入物与骨界面之间的失败。已有不少文献报道植入物-骨界面是临床上失败经常发生的部位。我们的模型也去除了多节段颈椎和胸椎上植入物固定点之间的活动的影响,并且由于使用了静态的位移控制试验,所以无法评估临床上常见的疲劳载荷导致的失败。最后,本研究的一个潜在的前提是,内植物刚度和机械强度的增加能够增加临床的成功率,这当然不一定是绝对的。
Further evaluation of these implants in a cadaver model using fatigue testing would help to assess the potential for screw pullout. Ultimately, only a controlled clinical trial can determine whether the mechanical properties reported here correlate with clinical success. Nonetheless, this mechanical study provides potentially useful information regarding the performance of the various posterior rod-and-screw constructs.
在尸体模型上对这些装置进一步进行疲劳实验,将有助于评估螺钉拔出的可能性。最终只有通过临床对照试验才能够知道这里所报道的机械性质与临床结果之间的关系。尽管如此,本研究还是可以提供一些关于不同后路顶棒装置性能的有价值的信息。

Provocative Discography and Lumbar Fusion Is Preoperative Assessment of Adjacent Discs Useful? 对融合腰椎的临近间盘进行术前诱发性椎间盘造影评价是否有用?
Paul C. Willems, MD,* Leon Elmans, MD,* Patricia G. Anderson, MA,Dick B. van der Schaaf, MD,* and Marinus de Kleuver, MD, PhD*
Study Design. A cohort study of clinical outcomes of lumbar fusion patients with preoperative assessment of adjacent levels by provocative discography. 研究设计. 对有融合临近间盘术前诱发性椎间盘造影评价的一组腰椎融合病人的临床结果进行研究.
Objective. To evaluate whether the preoperative status of the adjacent discs, as determined by provocative discography, has an impact on the clinical outcome of lumbar fusion in chronic low back pain (LBP) patients. 目的.评价临近间盘的术前状况(用诱发性椎间盘造影判断)是否对慢性下腰痛病人的腰椎融合的临床效果有影响
Summary of Background Data. The results of lumbar fusion in chronic LBP patients vary considerably and are hard to predict. It is believed that degenerative levels adjacent to a fused spinal segment may be a cause of continuing pain. In this respect, it is important to know whether preoperative degenerative or symptomatic adjacent levels have an adverse effect on patient outcomes after lumbar fusion. 背景资料简介.对慢性下腰痛病人进行腰椎融合,其效果变化相当大且很难进行预测.人们认为融合脊椎临近节段的退变程度可能是持续疼痛的原因.据此,知道术前临近节段退变或症状的程度是否对腰椎融合病人有不利影响是很重要的.
Methods. In 197 patients with an equivocal indication for lumbar fusion (two thirds were patients with prior spine surgery), the decision for either lumbar fusion or conservative management was determined by a temporary external transpedicular fixation trial. During the diagnostic workup, all patients had undergone provocative discography that included the assessment of the discs adjacent to the intended fusion levels. The individual changes in pain on a visual analog scale, assessed before treatment and at follow-up, and patient satisfaction were the measures of outcome. 方法.197个病人(其中2/3病人有脊柱手术史),可疑符合腰椎融合适应症,对病人决定实施腰椎融合或保守治疗取决于临时椎弓根外固定试验的效果。诊断治疗过程中,对所有病人进行诱发性椎间盘造影,其中包括评价预备融合节段的临近间盘。病人治疗前后疼痛的改变给与vas评分,病人的满意作为结果的量度标准。
Results. In the 82 patients who underwent a lumbar fusion, no difference in outcome was found between those patients with degenerative or symptomatic discs adjacent to the fusion and those with normal adjacent discs. 结果:82个病人被实施腰椎融合,融合临近节段有退变间盘或症状间盘的一组病人和临近节段正常间盘的另一组病人的腰椎融合结果无差别。
Conclusion. In this cohort study of chronic LBP patients with an uncertain indication for lumbar fusion, the preoperative status of adjacent levels as assessed by provocative discography did not appear to be related to the clinical outcome after fusion. 结论:在这组不能确定是否符合腰椎融合适应症的慢性下腰痛病人中,临近间盘的术前状况(通过诱发性椎间盘造影来评价)没有显示和融合后的临床效果有相关性。
Key words: chronic low back pain, lumbar spinal fusion, provocative discography, adjacent level, intervertebral disc.关键词 慢性下腰痛,腰椎融合,诱发性椎间盘造影,临近节段,椎间盘。
10. Serial Arterial Embolization for Large Sacral Giant-Cell Tumors: Mid- to Long-term Results
连续动脉栓塞治疗巨大骶骨骨巨细胞瘤:中远期随访结果

Although giant-cell tumors are typically considered to be benign tumors, they can be aggressive and can even metastasize. Giant-cell tumors of the sacrum are rare, as demonstrated in the Mayo Clinic series where they represented 8% of the 425 tumors treated over a period of 26 years. The sacrum is the most frequent site of occurrence in the axial skeleton. Sacral giant-cell tumors (SGCTs) are a challenging problem, as local recurrence rates are higher than that for any other location in the skeleton. These tumors tend to be clinically silent in the initial stages of development and cause few symptoms until they obtain a very large size. This normally precludes early diagnosis and ultimately allows these lesions to reach large sizes at initial presentation.
骨巨细胞瘤虽然通常被认为是良性肿瘤,但可能会有侵袭性甚至发生转移。骶骨骨巨细胞瘤罕见,据Mayo Clinic统计在过去26年里的425例肿瘤病例中只占8%。骶骨是中轴骨骼上最常见的发病部位。骶骨骨巨细胞瘤(SGCTs)的局部复发率要高于骨骼的其他部位,治疗较为困难。这些肿瘤在发展早期不会引起明显的临床症状与表现,除非发展得异常巨大。因此其难于早期诊断,并最终使得在初次发现时便已经非常巨大。
The preferred method of surgical treatment for a specific musculoskeletal tumor is usually based on the Enneking classification. The surgical techniques that can be used include intralesional, marginal, or wide margin resection. In the case of benign tumors, intralesional resection and bone grafting is often performed. For more aggressive benign tumors, marginal or wide excision is often recommended depending on the anticipated morbidity and resultant impairment of the chosen procedure.
对某种骨与软组织肿瘤来说,首选的外科治疗方法通常依据Enneking分型。可用的外科技术包括瘤内、边缘和广泛切除。良性肿瘤通常采用瘤内切除加植骨。对于侵袭性更强的良性肿瘤,则需要根据预期的病死率和操作带来的损害情况要求边缘或广泛切除。
While many tumors in the sacrum can be resected with wide or marginal margins without causing resultant pelvic instability or neurologic impairment, this is not the case for large, space-occupying giant-cell tumors. These tumors are not always amenable to surgical resection and thus, alternative modes of treatment should be considered. The optimal form of management for SGCTs remains controversial given the poor results and significant morbidity associated with traditional methods of treatment, including surgery and radiation therapy. While surgical treatment may be effective in some patients, it is technically difficult because of the anatomic location, high risk for severe hemorrhage, infection, and damage to neurologic structures. Furthermore, intralesional curettage with cementation and complete curettage with or without radiotherapy has been associated with high recurrence rates approaching 29%. Partial or en bloc sacrectomy is a more aggressive treatment modality that may be curative but necessitates sacrifice of the sacral nerve roots, thereby leading to possible bowel, bladder, or sexual dysfunction. Moreover, sacrectomy may cause pelvic instability that may necessitate additional surgery. Radiation is usually not the primary mode of treatment for giant-cell tumors, but is typically used as an adjuvant treatment combined with surgery. Primary radiation therapy, which often carries less morbidity than surgery, can have possible deleterious local effects, including late pathologic fractures, neuritis, and even radiation-induced sarcomas.
虽然骶骨上的许多肿瘤可以边缘或广泛切除,而不引起骨盆失稳或神经损伤,但巨大占位的骨巨细胞瘤并非如此。这些肿瘤并非总是适合外科切除,因此需要考虑其他的治疗方式。治疗SGCTs的最佳方案仍然存在争论,包括手术和放疗的传统方法,效果不佳并且病死率较高。尽管在某些病人手术治疗可能会有效,但由于解剖位置、大出血的高风险、感染和神经损伤的问题,在技术上难以成功。此外,瘤内刮除加骨水泥填塞术以及完全刮除联合或不联合辅助放疗术后的复发率高达接近29%。部分或全骶骨切除术更为激进,有治愈的可能,但需要牺牲骶神经,从而导致二便和性功能障碍。而且,骶骨切除引起的骨盆失稳,可能需要另外的手术。放疗不是治疗骨巨细胞瘤的主要方法,但通常作为手术的辅助治疗。单纯放疗的死亡率要比手术者低,但可能引起局部损伤,包括迟发性病理骨折、神经炎甚至放射诱发的肉瘤。
Given the significant morbidity associated with surgical resection and/or radiation therapy in large SGCTs, a minimally invasive and less morbid therapeutic alternative was devised. Intra-arterial embolization, a technique particularly useful for tumors located in the axial skeleton, has been shown to devascularize tumors, reduce their size, induce calcification of their margins, and alleviate pain. Serial arterial embolization for large SGCTs was initially conceived by the senior author (R.D.L.) as a less morbid form of primary treatment. Early results proved embolization to be a unique, potentially effective way of dealing with large giant-cell tumors that may prove difficult to surgically resect. This minimally invasive mode of therapy facilitates effective treatment of large tumors that are not amenable to surgical resection and can potentially serve as a useful primary treatment modality given the lower morbidity and mortality relative to surgery and radiation. Although there are limitations of this procedure, including multiple required procedures and potential failure of treatment, adjuvant radiation therapy and, in rare circumstances, even surgical resection can be offered.
基于巨大SGCTs手术切除联合/不联合放疗的较高死亡率,我们提出了一种微创并且并发症较小的治疗方法。对于中轴骨肿瘤具有独特优势的动脉栓塞技术,已证实具有减少肿瘤血管、缩小肿瘤体积、诱导边缘钙化和止痛的作用。连续动脉栓塞治疗巨大SGCTs首先由资深作者(R.D.L)提出作为较少并发症的主要治疗措施。初步结果表明栓塞可能是治疗无法外科切除的巨大骨巨细胞瘤的一种独特的、可能有效的方法。这种微创的方法可用于治疗不适于外科切除的巨大肿瘤,并且相对于手术加放疗来说,发病率和死亡率均较低。虽然这种过程有其局限性,比如多次重复操作和潜在的治疗失败可能,但仍然可以进行辅助放疗,甚至在某些的情况下行手术切除。
We previously presented our early results with this novel technique as a primary treatment modality for SGCTs. In this current report, we present the longterm outcomes of those patients that were previously described and the mid-term results of additional cases treated in the interim period.
我们之前已经报告了这种新技术作为SGCTs主要治疗方法的早期结果。在本文中,我们将报告以前那些病人的长期结果以及后来添加的病人的中期结果。
Materials and Methods
材料与方法
Following IRB approval, we used the tumor database of the Department of Orthopedic Oncology at the University of Pennsylvania to identify all consecutive cases of SGCTs treated between 1984 and 2006. A minimum of 36 months of follow-up was required for inclusion in the study. Nine cases of SGCTs were identified and the hospital charts, clinic notes, and radiographs, including advanced imaging and angiograms for each patient were reviewed. In addition, we clinically examined all survivors to assess their functional status and performed a cross-sectional review of their Musculoskeletal Tumor Society Rating Scale (MSTS) scores, which was conducted by an independent evaluator, at final follow-up.
得到IRB批准,我们利用了宾夕法尼亚大学骨肿瘤系的肿瘤数据来辨别1984到2006年之间治疗的所有SGCTs病例。研究中随访的最短时间为36个月。识别了9例SGCTs,回顾了每个病人的医院病历、诊断笔记和包括高级成像和血管造影在内的X光片。另外,我们临床检查了所有存活的病历以评估其功能状态并进行了MSTS评分的横断面回顾,评分由一名独立的评测人在最后一次随访中进行。
The review parameters included age and symptoms at presentation (including neurologic dysfunction and bowel/bladder involvement), gender, Campanacci grade of the sacral lesion, anatomic location of the tumor within the sacrum, tumor measurement in 3 dimensions, history of previous treatment, total number of arterial embolizations received, follow-up in years, and MSTS score at final follow-up. For the purposes of this study, we defined any lesion greater than 5.0 cm in more than 2 dimensions as a large giant-cell tumor. Considering the anatomy of the sacrum, lesions were classified as central, right paracentral, or left paracentral in the anteroposterior plane and anterior or posterior in the sagittal plane (Figure 1). Details of these parameters for each individual case are presented in Table 1. The diagnosis of giant-cell tumor was confirmed in all cases with biopsy (Figure 2).
回顾的参数包括发病时的年龄与症状(包括神经障碍和二便),性别,骶骨病灶的Campanacci分级,肿瘤在骶骨内的解剖位置,肿瘤的三维测量,先前的治疗史,接受的动脉栓塞的次数,随访的年限以及最后一次随访的MSTS得分。我们定义在二维或三维上任何大于5cm的病灶为巨大骨巨细胞瘤。考虑到骶骨的解剖位置,病灶被分为冠状面上的中央、右侧和左侧,以及矢状面上的前、后(figure 1)。每个病例的具体参数见table 1。所有病例的骨巨细胞瘤的诊断都经病理证实(figure 2)。
All patients were primarily treated with serial arterial embolization using the technique described below. Given the fact that all of these lesions were large at presentation, the decision was made to proceed with a less morbid mode of primary intervention in the form of serial arterial embolization.
所有病人均接受了下面提到的连续动脉栓塞治疗技术。考虑到这些病灶都很大,因此我们决定进行对其连续动脉栓塞以减少并发症。
Arterial Embolization Technique. Intra-arterial embolization was performed using femoral access to selectively embolize the main arteries feeding the tumor. Angiography was performed at the beginning of each treatment session to identify arteries of adequate caliber to facilitate embolization (Figure 3). The arteries were embolized based on the arterial supply to the sacrum, resulting in occlusion of the internal iliac, lateral sacral, lumbar, iliolumbar, and median sacral arteries. Selective delivery of substances including gelfoam particles, polyvinyl alcohol, and stainless steel coils were used to achieve central occlusion of the vessel. The primary goal of arterial embolization was to successfully occlude the blood supply to the tumor through obstruction of the feeder vessels. Relative success of one embolization agent over another is beyond the scope of this particular study. Successful embolization was confirmed with repeat angiography. It is noteworthy that as this study extends over 2 decades, the methodologies used by interventional radiologists have evolved to include better means of embolization. However, as the ultimate goal was to block the feeder vessel in all cases, we have chosen to not focus on variations in embolization techniques.
动脉栓塞技术:动脉栓塞的方法是利用股动脉途径进行选择性栓塞肿瘤的主要动脉。每次治疗开始的时候都进行血管造影以识别便于栓塞的适合粗细的动脉(figure 3)。在供应骶骨的动脉的基础上进行动脉栓塞,从而闭塞了髂内动脉、骶横动脉、腰动脉、髂腰动脉以及骶中央动脉。选择性栓塞物包括明胶海绵颗粒、聚乙烯醇和不锈钢螺圈。栓塞的主要目的是闭塞破坏供应肿瘤的主要血管。栓塞物之间的对比不在本次研究的讨论范围。栓塞的成功与否经动脉造影证实。值得注意的是,本研究持续了超过20年,介入放射学家所使用的这一方法已经演变出许多种栓塞的方法。尽管如此,由于最终的目的还是闭塞供养血管,因此我们并未关注不同的栓塞技术之间的差别。
All patients underwent initial angiography and embolization at the time of diagnosis. Subsequent angiography and embolization occurred every 6 weeks until no new vessel formation was evident. It is important to note that these lesions frequently form a collateral blood supply following occlusion of the main feeder vessels. Obstruction of the primary vessels during the initial procedure leads to significant blood flow through the major collaterals that can be identified through subsequent angiograms. Ultimately, these vessels were treated as the new primary feeders, until such a time that the collateral circulation became either negligible or was not noted on angiography (Figures 4, 5). Additional angiography was performed at 6 and 18 months to assess tumor progression or stabilization. Any return of symptoms or radiologic progression of the lesion was evaluated and treated with further angiography and embolization. The results of embolization were evaluated by clinical examination, functional evaluation, and advanced imaging studies. Patients were closely monitored with serial imaging of the pelvis, using MRI or CT scan, every 6 months for 5 years and annually thereafter. Patient outcome was measured using the Musculoskeletal Tumor Society Rating Scale 1993 (MSTS93), a clinician-completed assessment of impairment measuring specific activity-based clinical measures, including pain, function, emotional acceptance, supports, walking ability, and gait. Patients were asked to rate each individual clinical measure on a scale of 1 to 5, with 5 points representing an excellent outcome. Additional measures used to evaluate patient outcomes included radiologic changes in the size of the lesion, calcification of the tumor margins, and the development of pulmonary metastases.
所有病人在诊断时便接受了初次的动脉造影和栓塞。之后的血管造影和栓塞每6周进行一次,直至没有明显的新生血管形成。需要注意的是这些病灶的主要血管被栓塞之后常常还会形成侧枝血供。初次治疗破坏了主要血管之后,主要侧枝动脉的血流量会明显增加,这可以通过后来的血管造影进行识别。最终,这些血管又反复被作为新的主要血管进行栓塞,直至侧枝循环可以忽略不计或血管造影无法发现为止(figure 4、5)。在6和18个月时重复进行血管造影,以评估肿瘤是进展还是稳定。任何症状的复发或影像学上病灶进展都得到了评估并进行了重复血管造影和栓塞治疗。栓塞的结果通过临床检查、功能评估和高级成像来进行评估。患者通过多次的骨盆MRI或CT成像进行密切检测,5年以内每6个月一次,之后每年一次。患者的预后用MSTS93进行测量,这是一种由临床医师完成的临床测量,内容包括疼痛、功能、主观接受程度、援助、行走能力和步态。患者被要求对每个单独的临床指标进行1到5的分级,5分代表优秀。其他用于评估患者预后的测量包括病灶大小的影像学改变、肿瘤边缘的钙化和有无肺转移的进展。
Results
结果
Nine consecutive patients (8 females and 1 male) underwent serial arterial embolization for large SGCTs between 1984 and 2006. All patients underwent open or needle biopsy. Following histologic review and advanced imaging, 6 lesions were classified as Campanacci Grade II and 3 lesions were classified as Grade III. The mean age was 31 years (range, 19–56 years) at the time of diagnosis. All patients presented with complaints of pain localized to the back or buttock. The mean pretreatment pain score was 8.55 (range, 7–10) on a scale of 1 to 10, with a score of 10 representing severe pain. None of these patients had undergone previous treatment before presentation. Arterial embolization was the initial treatment in all of our cases, and the sole treatment used in 7 patients. The mean number of embolizations was 4.8 (range, 3–7). The mean post-treatment pain scale was 1.44 (range, 0–3).
在1984到2006年之间,先后有9名患者(8女1男)因巨大SGCTs接受了连续动脉栓塞治疗。所有患者都接受了切除或穿刺病理活检。根据组织学检查与高级成像,6例病灶为Campanacci II级,3例为III级。诊断时的平均年龄为31岁(范围,19-56岁)。所有患者的主诉都为背部以及臀部疼痛。治疗前平均疼痛评分为8.55分(范围,7-10分),疼痛标尺为1-10分,10分代表最痛。在发病之前所有患者均未接受过治疗。我们的这些病例的初次治疗都是动脉栓塞,其中7例为唯一的治疗措施。栓塞的平均次数为4.8次(范围,3-7次)。平均术后疼痛评分1.44分(范围,0-3)。
In order to assess the size of the lesion, the greatest dimensions in the sagittal, axial, and coronal planes on MRI or CT imaging were measured. The specific anatomic location of the lesion within the sacrum was also noted for each patient (anteroposterior plane: central, right paracentral, or left paracentral; sagittal plane: anterior or posterior). The location and measurements of all 9 lesions are summarized in Table 1.
为了评估病灶的大小,测量了MRI或CT图像中矢状面、水平面和冠状面上的最大长度。每位患者都记录了病灶在骶骨内的特殊的解剖位置(冠状面:中央、右侧或左侧;矢状面:前或后)。9例病灶的位置和测量值见table 1。
Of the 9 patients that underwent serial arterial embolization, 7 experienced a favorable radiographic response, with no notable progression in tumor size. Indeed, these patients demonstrated a decrease in tumor size with the maximum regression measuring 3.3 cm in 1 patient. Additionally, there was a clear decrease in the vascularity of these tumors and an increase in peripheral ossification on CT scan and radiographic imaging (Figures 6, 7).
在接受连续动脉栓塞治疗的9名患者中,7名的放射学表现良好,未见肿瘤大小有明显进展。而且这些患者的肿瘤大小还有所减小,缩小最显著的一名患者的最大长度减少了3.3cm。另外,这些肿瘤的血管供应显著减少,而且在CT扫描和X线图像上可见外周骨化增加(figures 6,7)。
Two of 9 patients demonstrated progression of tumor growth (Cases 7 and 8). Both patients experienced an increase of less than 1 cm during early treatment with embolization, thereby prompting further treatment with adjuvant therapy. The first patient (Case 7) demonstrated gradual tumor progression over 30 months, and subsequent radiation therapy was successful in achieving local tumor control. At 92-month follow-up, the patient was doing well physically, as she enjoyed full function with an overall MSTS score of 29, and she had no complaints of pain. The second patient (Case 8) reported substantial pain relief following initial embolization; however, she returned 1 month later complaining of back pain. Radiologic studies revealed growth of the tumor 6 months following serial embolization therapy and 500 Gy of external beam radiation was subsequently administered in attempt to halt further advancement of the tumor. Radiation therapy did not improve her symptoms or prevent further tumor growth. While the patient had a normal chest radiograph at the time of initial diagnosis, she developed pulmonary metastases 6 months following local radiation. Further biopsy specimens were obtained at this time, and the histologic slides were sent to 2 other tertiary referral institutions for repeat review. Pathologists confirmed the diagnosis as benign giant-cell tumor. The patient received multiagent systemic chemotherapy shortly thereafter but experienced multiple metastases and died 18 months later (3.8 years following the initial embolization therapy). One can only hypothesize that the lesion may not have been a true giant-cell tumor, but rather a rare variant of osteosarcoma given its clinical pattern of behavior.
9名患者中有2名发现肿瘤有生长(病例7和8)。2名患者在栓塞治疗的早期都发现有小于1cm的增大,因此需要进一步辅助治疗。1名患者(病例7)表现为肿瘤在30个月里逐渐增大,后来的放疗成功控制住了局部肿瘤。经过92个月的随访,这名患者一般情况好,无明显功能障碍,MSTS评分为29分,无疼痛主诉。另一名患者(病例8)在初次栓塞后疼痛有显著缓解,然而在1个月以后她又因为背部疼痛就诊。影像学显示在连续血管栓塞之后6个月肿瘤仍然有生长,之后给予500Gy的外线束放疗以试图控制肿瘤进展。但放疗没有改善症状以及控制肿瘤生长。与患者在初次诊断时的常规胸片相比,她在局部放疗后6个月发现肺部转移。重新取活检标本并将组织学切片送到2个第三方治疗机构读片。病理学证实为良性骨巨细胞瘤。此后不久患者接受了联合系统化疗,但还是出现了多发转移,最终在18个月后死亡(距初次栓塞治疗3.8年)。该病灶可能并非真正的骨巨细胞瘤,而是一种少见的骨肉瘤变型形式。
The mean duration of follow-up in this series was 8.96 years (range, 3.8–21.2 years) with a median of 7.8 years. Cross-sectional MSTS93 scores were obtained in the 8 surviving patients at their most recent follow-up visit. These were solicited by an independent evaluator (medical student) and results are summarized in Table 2.
这些病例的平均随访时间为8.96年(3.8-21.2年,中位数7.8年)。8例存活患者最近随访的MSTS93断层得分,由一名独立的评估者获得(医学生),结果见table 2。
Overall, all survivors reported substantial pain relief following serial embolization. While 1 patient died from tumor metastases, the 8 remaining patients have not experienced metastases, and they were all asymptomatic at their last follow-up. All patients continue to undergo annual clinical and radiologic review. In a questionnaire survey, all patients expressed complete satisfaction with their treatment and pain relief and noted that if given a therapeutic choice, all of them would prefer serial embolization therapy over surgery or radiation as a primary modality. Of note, 1 patient (Case 4) underwent surgical intervention for sacroiliac joint symptoms. Despite a positive response to serial embolization, significant tumor encroachment before initiation of arterial emboliza-tion treatment led to severe cortical thinning of the sacral area and subsequent sacroiliac instability. Following successful therapy with serial embolization, this patient underwent in situ lumbosacral fusion 2 years after the diagnosis (Figure 8). Following surgery, her symptoms improved dramatically; and at her most recent follow-up visit (11.1 years), she was pain free and continued to enjoy full function.
总之,所有存活的患者都表示在连续栓塞之后疼痛有显著缓解。尽管一名患者发生了肿瘤转移,另外8名并未出现转移。所有患者仍然继续每年一次的临床与影像学的评估。在一项问卷调查中,所有患者都对他们的治疗以及疼痛缓解情况,表示完全满意,并声称若能再次选择话,仍然会选择动脉栓塞作为主要的治疗方式。一名患者(病例4)由于骶髂关节症状接受了手术干预。尽管连续栓塞治疗的效果较好,但肿瘤在初次栓塞之前的大范围侵犯,导致了严重的骶骨皮质变薄以及后来的骶髂关节失稳。在成功的连续栓塞治疗之后,这名患者在确诊2年后接受了原位的腰骶融合(Figure 8)。术后症状极大改善,在最近的随访中,该患者无疼痛主诉以及功能障碍。
Discussion
讨论
Giant-cell tumors of the sacrum are very rare. They are often very large at initial presentation, and it is their size coupled with their precarious location that makes them difficult to treat. Indeed, several studies attribute size and location as the primary reasons for local recurrence rates of SGCTs being higher than those observed in other anatomic areas. To date, surgical resection and adjuvant radiation therapy have been considered the traditional treatment methods for these tumors.
骶骨的骨巨细胞瘤非常罕见。它通常在初次发病时便已十分巨大,其大小和位置使得治疗非常困难。并且有好几项研究表明大小和位置是SGCTs局部复发率高于其他解剖位置的主要原因。至今为止,手术切除和辅助放疗被认为是治疗这些肿瘤的传统方法。
While shown to be curative, total sacrectomy can produce large osseous and soft tissue defects that lead to vertical and rotational instability, necessitating reconstructive surgery. Reconstructive surgery often leads to further complications, particularly related to excessive intraoperative blood loss and postoperative wound healing. Furthermore, sacral resection carries a high incidence of neurologic complications depending on the level of resection, potentially leading to bowel, bladder and sexual dysfunction. Studies investigating the efficacy of intralesional curettage have demonstrated high recurrence rates. In a study by Goldenberg et al, researchers reported a 100% recurrence rate in 5 SGCTs treated with curettage alone. Turcotte et al also demonstrated high recurrence rates (33%) in patients undergoing complete curettage for tumors localized to the sacrum. In a comprehensive review of the literature by Leggon et al, the authors revealed recurrence rates approaching 47% for patients who had surgery with intralesional margins. Postoperative adjuvant radiotherapy demonstrated limited benefits in the improvement of these results, as these authors reported the local recurrence rate was 46% for patients who had surgery with intralesional margins and radiation therapy. Interestingly, they discovered that recurrence after surgery and radiation was not lower than after either treatment alone.
全骶骨切除尽管有治愈的可能,但会造成巨大的骨与软组织缺损,导致垂直和旋转的不稳定,从而需要进行重建手术。重建常常带来更多的并发症,特别是术中大量出血以及术后切口愈合的问题。另外,骶骨切除依据节段,还会带来较多的神经系统并发症,可能会导致二便以及性功能障碍。关于病灶内部刮除的研究表明复发率较高。Goldenberg等的一项研究报告,5例单纯行刮除的SGCTs的患者的复发率为100%。Turcotte等也报告骶骨肿瘤接受完全刮除的病人的复发率较高(33%)。Leggon等的一篇综合的文献复习显示,接受边缘内手术的病人的复发率高达47%。术后辅助放疗对预后的改善也有限,上述作者报道接受边缘内手术加放疗病人的复发率达到46%。有意思的是,手术加放疗的复发率并不比单用任何一种治疗的低。
Primary radiotherapy, although less morbid than surgery, has not demonstrated favorable results, and there is a concern that sarcomas can arise following irradiation. A recent study reviewed 239 giant-cell tumors of the sacrum or pelvis and found radiationinduced sarcoma developed in 11% of patients who received radiation for primary or recurrent lesions at a follow-up period of 5 years or more. While the authors note that the substantial field of radiation that is required in the treatment of these exceptionally large tumors may be contributory, this high rate of sarcomatous change is cause for concern. In addition to these serious complications, radiotherapy has been associated with variable success rates. In a study by Chakravarti et al, researchers used megavoltage radiotherapy for the treatment of inoperable giant-cell tumors. Twenty patients with giantcell tumor of bone were followed for a mean duration of 9.3 years and of the 5 patients with sacral lesions, 2 (40%) were reported to have local recurrence at 5 and 8 months.
放疗虽然比手术的损伤要小,但效果也不令人满意,而且令人担忧的是辐射还有可能诱发骨肉瘤。最近的一项研究回顾了239例骶骨或骨盆的骨巨细胞瘤,对初发的或复发的病灶行放疗后随访5年以上,发现有11%的患者出现了放疗诱发的骨肉瘤。虽然作者声称治疗这些异常巨大的肿瘤所要求的照射野可能对疾病有益,但如此高比例的肉瘤样变还是令人担忧的。除了这些并发症以外,放疗的有效率也是高低不一。Chakravarti等人在一项研究中使用超高压放疗治疗无法手术的骨巨细胞瘤患者。20名患者随访了平均9.3年,其中在5名骶骨区病灶的患者里,2名(40%)在术后5和8个月发现有局部复发。
The results of arterial embolization for the treatment of SGCTs have been encouraging. While selective intraarterial embolization was initially used to provide symptomatic pain relief and control intraoperative blood loss, it has gained widespread popularity as an alternative primary treatment modality. An early study with shortterm follow-up by Wallace et al described 9 patients with primary and secondary tumors of the pelvis, including 3 patients with giant-cell tumors. The authors used gelfoam and stainless steel coils to achieve arterial occlusion. Eight patients (88.8%) reported symptomatic pain relief and 2 patients (66.7%) with giant-cell tumors experienced calcification of the tumor periphery along with a 15% decrease in overall size. A similar study by Chuang et al investigated the efficacy of arterial embolization using gelfoam and stainless-steel coils as a palliative procedure for surgically unfavorable giant-cell tumors and aneurysmal bone cysts. Five of these lesions failed previous therapy with either irradiation and chemotherapy or chemotherapy alone. Of note, the authors reported that repeat embolization was required in 4 patients to adequately occlude the feeding vessels. Seven patients experienced significant pain relief and 5 patients developed substantial calcification of the tumor margins following treatment. We previously presented early results of 5 patients with SGCTs that were primarily treated with serial arterial embolization.
动脉栓塞治疗SGCTs的结果是令人鼓舞的。尽管选择性动脉内栓塞最初是用来缓解疼痛以及控制术中出血,但它作为一种治疗方式已被广泛接受。Wallace等在早期一个随访时间较短的研究中描述了9名骨盆原发和继发肿瘤的患者,其中包括3名骨巨细胞瘤患者。他们利用可吸收明胶海绵和不锈钢钢圈来阻塞动脉。8名患者(88.8%)报告疼痛缓解,2名骨巨细胞瘤的患者(66.7%)的肿瘤边缘出现钙化并且体积减小了15%。Chuang等的一项类似研究调查了利用可吸收明胶海绵以及不锈钢钢圈行动脉栓塞,作为无法手术的骨巨细胞瘤和动脉瘤样骨囊肿患者的姑息治疗方法的效果。其中5名患者之前的放疗联合化疗或单纯化疗均失败了。值得注意的是,作者报告其中4例患者需要行再次栓塞以充分阻塞供养血管。7名患者疼痛显著缓解,5名在治疗后肿瘤边缘出现钙化。我们先前也报道过5名主要接受动脉栓塞治疗的SGCTs患者的早期结果。
There are some data regarding the long-term follow-up of patients who are treated with arterial emboli-zation. Lin et al presented a long-term follow-up of patients with giant-cell tumors of the sacrum treated with selective arterial embolization in 2002. Eighteen patients were treated with selective intra-arterial embolization with a combination of gelfoam particles and coils for peripheral and central occlusions. Nine patients received intra-arterial cisplatin as a part of their treatment. Mean and median follow-up was 12.8 and 9.1 years, respectively. Of the 18 patients that were studied, 14 had favorable results and reported improvement in pain and neurologic symptoms with demonstrable reossification and stabilization of tumor size on CT and MRI imaging. Three patients developed late recurrent disease within the sacrum. Kaplan-Meier analysis revealed that the risk of local recurrence was 31% at 10 years and 43% at 15 and 20 years. Long-term results were not affected by intra-arterial cisplatin. Our early results with this technique (serial arterial embolization) were also published in 2002. It is interesting to note that the results of Lin et al parallel the responses noted in our group of patients. However, we are not in favor of using intra-arterial cisplatin, as this chemotherapeutic agent has distinct associated morbidity. Furthermore, the study by the Lin et al study did not show any conclusive role of cisplatin.
还有一些其他关于动脉栓塞治疗的长期随访的数据。Lin等在2002年报道过一份关于骶骨骨巨细胞瘤患者接受选择行动脉栓塞治疗的长期随访结果。18名患者接受了选择行动脉栓塞,所使用的栓塞物为包裹可吸收明胶海绵的钢圈。9名患者还同时接受了动脉内注射顺铂化疗。平均和中位随访年限分别为12.8和9年。18名患者中,14名的效果满意,疼痛和神经症状改善,而且在CT和MRI图像上可见重新骨化以及肿瘤体积稳定。3名患者出现骶骨内的远期复发。Kaplan-Meier分析显示10年局部复发风险为31%,15年和20年的均为43%。动脉内注射顺铂化疗对长期的结果没有影响。我们关于这一技术的早期结果同样发表在2002年。有意思的是Lin等的结果与我们这边的病人反应非常类似。尽管如此,由于化疗药物可能带来的特殊的相关问题,我们不倾向于使用动脉内注射顺铂。此外,Lin等的研究也没有显示顺铂有明确的作用。
For the purposes of this study, we defined large SGCTs as any lesion that was >5 cm in at least 2 dimensions. All of the SGCTs treated consecutively by the senior author since 1984 met these predetermined criteria. All of the identified cases were Campanacci Grade II or III lesions. Of the 22 SGCTs noted at the M. D. Anderson Cancer Center between 1975 and 1997 (Lin et al), 9 were
primarily treated with selective arterial embolization while 9 were treated with combined embolization and chemotherapy. Of the remaining 4 cases, 3 were treated with surgery without embolization and one was treated with chemotherapy alone. The authors did not elaborate on their specific indications for primary therapy with arterial embolization, nor did they comment on the
Campanacci grades or dimensions of the tumors before and after treatment. In any case, it is important to note that 82% (18 of 22) of SGCTs managed at the M. D. Anderson Cancer Center and 100% (9 of 9) at the University of Pennsylvania have been primarily managed for over 2 decades with serial arterial embolization. An important conclusion from this analysis would be that long-term results with this technique are comparable and reproducible when performed in 2 independent, tertiary level orthopedic oncology referral centers.
基于本研究的目的,我们定义巨大SGCTs为任何在二维或三维层面上大于5cm的病灶。从1984年以来,所有由主要作者治疗的SGCTs均符合这一标准。所有经鉴定的病例都是Campanacci II级或III级。M. D. Anderson癌症中心(Lin等)于1975到1997年之间记录的22例SGCTs中,9例接受了选择性动脉栓塞治疗,9名接受了栓塞联合化疗治疗。剩下的4名患者中,有3例进行了手术,没有做栓塞治疗,另1名单纯接受了化疗。作者并没有详细说明关于选择动脉栓塞疗法的适应症,也没有评价治疗前后的Campanacci分级或肿瘤大小。无论如何,M. D. Anderson癌症中心治疗的82%的SGCTs(22例中18例)和宾夕法尼亚大学的100%病例(全部9例)都已经各自进行了超过20年的连续动脉栓塞治疗。这一分析得到的重要结论是,在2个独立的、三级骨肿瘤转诊中心获得的,关于这种技术的长期结果是可比的和可重复的。
We have presented mid- to long-term results of 9 cases using serial arterial embolization as a primary treatment modality for SGCTs. Intra-arterial embolization was the sole method of treatment in 7 of 9 patients, and adjuvant therapy was required in 2 of these cases. While we experienced minimal early progression of disease in 2 patients in our series, none of our patients has experienced late disease recurrence at a mean duration of 8.96 years (median, 7.8 years) with up to 21.2 years follow-up in the index case. The majority of patients in our series demonstrated a positive clinical and radiographic response to embolization. Our results along with those reported by Lin et al demonstrate reossification and stabilization of tumor size can be achieved on CT and MRI imaging following serial arterial embolization. All of the patients reported substantial pain relief following embolization and MSTS scores revealed favorable functional outcomes. All patients remain active with full range of motion in their lower extremities and they have no complaints of bowel, bladder, or sexual dysfunction. Although previous studies using arterial embolization for other spinal tumors have reported nerve injury secondary to ischemia, we have not experienced any complications with this technique at long-term follow-up.
以上我们报告了经连续动脉栓塞治疗的9例SGCTs患者的中远期结果。9例中的7例只接受了动脉内栓塞治疗,另外两名需要接受辅助治疗。虽然我们在2名患者中发现轻微的早期进展,但在最长达21.2年、平均8.96年(中位年限7.8年)的随访期间,我们没有发现远期复发的情况。我们的大多数病人在临床和影像学上都显示了对栓塞的良好反应。我们和Lin等的结果都表明连续动脉栓塞术后在CT和MRI上可以见到重新骨化和肿瘤大小的稳定。所有的患者都声称栓塞术后疼痛明显缓解,MSTS评分证实功能结果满意。所有患者的下肢活动无受限,并且没有关于二便和性功能障碍的主诉。虽然之前关于动脉栓塞治疗其他脊柱肿瘤的研究报告过局部缺血引起的神经损伤,我们在此技术的长期随访过程中没有见到任何相关的患者主诉。
Conclusion
结论
This study demonstrates positive mid- to long-term outcomes of patients that underwent intra-arterial embolization as a primary treatment modality for sacral giant-cell tumors. Our favorable results combined with those reported by Lin et al at the M. D. Anderson Cancer Center indicate that serial arterial embolization deserves consideration as a primary treatment modality for this challenging disease, especially in light of the widely recognized morbidity and mortality associated with alternative therapies that are available today.
本研究表明骶骨骨巨细胞瘤患者接受动脉内栓塞作为主要疗法,其中远期疗效肯定。我们以及M. D. Anderson癌症中心的Lin等报告的令人满意的结果显示,与已有疗法所带来的公认的并发症和死亡率相比,连续动脉栓塞值得考虑作为这种具有挑战性的疾病的主要疗法。
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