经皮置钉开放微波消融术治疗脊柱转移瘤

Microwave ablation combined with percutaneous fixation and open decompression treat oppressive spinal metastasis

目的探讨经皮置钉开放减压术并行微波消融术在脊柱转移瘤治疗中的可行性和治疗效果。方法收集2015年1月至2018年9月共20例(26个转移灶)采用经皮置钉开放减压术并行微波消融术进行治疗的脊柱转移瘤患者资料,男13例,女7例;年龄(43.85±18.67)岁(范围:16~79岁)。病变部位:胸椎9例,腰椎11例。肿瘤类型:骨髓瘤2例,白血病1例,肝癌4例,骨肉瘤2例,肺癌5例,肾癌1例,食管癌1例,子宫颈癌1例,肠癌1例,前列腺癌1例,腺样囊性癌1例。术前均行CT扫描或MR检查明确转移灶部位及大小,设计相应微波消融范围。术中经皮微创置入椎弓根螺钉,局部肿瘤减压联合微波消融灭活肿瘤,消融过程中采用测温针分别对消融范围边缘和椎体后壁的温度进行实时监控,并采用冰生理盐水冷循环降温保护重要组织;13例行骨水泥灌注椎体成形术。术后采用疼痛视觉模拟评分(visual analogue scale,VAS)评分评价疼痛缓解效果;采用Frankel分级和美国东部肿瘤协作组(Eastern Cooperative Oncology Group,ECOG)评分等评估神经功能及体能状态。结果术中微波消融时间(5.43±2.07)min(范围:3~10 min);微波功率40~60 W。术中出血量(852.50±514.40)ml(范围:100~1700 ml);手术时间(4.11±0.99)h(范围:2.5~6.0 h)。病灶中心温度控制为70~85℃,周围组织温度通过冰盐水控制<43℃。20例均获得随访,随访时间(8.45±2.01)个月(范围:6~14个月),至末次随访无一例出现局部复发。所有患者术后疼痛均得到明显缓解,术后48 h、1个月、3个月、6个月的VAS评分为(1.55±1.23)分、(2.70±0.87)分、(2.40±1.14)分及(3.05±1.00)分,与术前的(5.95±1.18)分相比,差异均有统计学意义(P<0.05)。术后患者的神经功能及体能状态均明显改善,15例术后6个月Frankel分级至少改善了1个等级,并且8例患者术后6个月ECOG评分均得到显著改善。1例术后出现下肢肌力减退,经对症治疗后1个月内神经功能恢复正常。结论微波消融联合经皮置钉开放减压术能够有效地缓解脊柱转移瘤患者的疼痛,解除脊髓及神经压迫,重建脊柱稳定性,改善患者远期生存质量,是一种安全、有效的姑息治疗方法。

Objective To evaluate the safety and efficacy of the treatment for oppressive spinal by microwave ablation combined with percutaneous fixation and open decompression.Methods From January 2015 to September 2018,20 patients with 26 spinal metastatic were treated with microwave ablation combined with percutaneous fixation and open decompression,including 13 males and 7 females with an average age of 43.85±18.67 years(range,16-79 years).The locations of the lesions included:9 in the thoracic,11 in the lumbar.The tumors'type:myeloma 2 cases,leukemia 1 case,liver cancer 4 cases,osteosarcoma 2 cases,lung cancer 5 cases,kidney cancer 1 case,esophagus cancer 1case,cervical cancer 1 case,intestinal cancer 1 case,prostate cancer 1 case,adenoid cystic cancer 1case.Preoperatively all the patients suffered with the local pain and the spinal cord or nerve root compression symptoms.All 20 cases were examined with CT or MRI to determine the lesions and the sizes of metastasis,as well as to evaluate the ablation zone.The entry of the pedicle screws were performed by Wiltse method through paravertebral muscles.After that the lesions were treated with partial resection for decompression of spinal cord or nerve root,and followed with microwave ablation at the metastasis site.Thermometer was used to monitor the temperature at the central and posterior edges of the vertebral body.The surrounding important tissue were cooled by ice saline.13 patients were performed with vertebroplasty for enhancement the intensity of the vertebral body.The visual analogue scale(VAS)score was used to evaluate the effect of pain relief after surgery.The postoperative neurological function and performance status were evaluated using Frankel grading and Eastern Cooperative Oncology Group(ECOG).Results Each lesion was heated for 5.43±2.07 min(range,3-10 min).The power of microwave ablation was 40-60 W.The mean blood loss during operation was 852.50±514.40 ml(range,100-1700 ml).The mean operating time was 4.11±0.99 h(range,2.5-6.0 h).The temperature inside the lesion was 70-85℃.The temperature of the surrounding tissue was maintained at<43℃by repeated frozen saline flush.All cases were followed up for 8.45±2.01 months(range,6-14 months)without any recurrence.The VAS score of the 20 patients at 48 h,1 month,3 months and 6 months after operation were 1.55±1.23,2.70±0.87,2.40±1.14 and 3.05±1.00 points,which were all statistically lowerthan the preoperative score 5.95±1.18(P<0.05).The Frankel grading of 14 patients had at least one grade improvement 6 months after operation.There were 8 patients shown markedly improved ECOG score 6 months after surgery.Only one case suffered from reduced myodynamiaof lower limb and covered in one month after system treatment.Conclusion The microwave ablation combined with percutaneous fixation and open decompression could resolve the spinal and nerve compression,relieve the pain in metastatic spinal oppression,reconstruct the stability,and improve the quality of lives,which is a safe and effective palliative surgical method.