脊柱转移瘤临床、病理及手术治疗的演变:多中心回顾性研究

The trend of clinical and pathological characteristics and surgical treatment in patients with spinal metastases: A multicenter retrospective study

目的回顾性分析接受外科干预的脊柱转移瘤患者资料,总结其临床、病理特征及手术方式的演变规律。方法回顾性收集2007年1月至2018年12月703例脊柱转移瘤住院手术患者资料,男395例(56.19%,395/703),女308例(43.81%,308/703);年龄(58.14±11.46)岁(范围13~84岁)。手术类型按照侵袭程度和肿瘤切除彻底性分为:微创手术、减压手术、分离手术、分块切除手术及整块切除手术。其中微创手术89例(12.66%),减压手术96例(13.66%),分离手术303例(43.10%),分块切除手术182例(25.89%),椎体整块切除手术33例(4.69%)。分析随年代的不同脊柱转移瘤患者临床、病理类型及手术治疗的演变规律,采用多因素logistic回归确定影响手术方式决策的相关因素。结果703例的男女比为1.28∶1。39.54%的患者(278/703)单节段受累,24.04%的患者(169/703)为双节段转移,36.42%的患者(256/703)为多节段转移。原发肿瘤类型:最常见的为肺癌(34.57%,243/703),其次为乳腺癌(8.25%,58/703)、骨髓瘤(8.11%,57/703)、胃肠道肿瘤(6.82%,48/703)、肾恶性肿瘤(6.40%,45/703)。2007年至2018年12年中不同年龄、性别、原发肿瘤来源构成百分比变化的差异无统计学意义(χ^(2)_(年龄)=14.01,P年龄=0.233;χ^(2)_(性别)=35.73,P性别=0.341;χ^(2)_(原发肿瘤类型)=120.09,P原发肿瘤类型=0.074)。骶尾椎转移患者百分比由2008年20.00%下降至2017年1.89%,差异有统计学意义(χ^(2)=8.09,P=0.005);多节段转移患者百分比由2008年26.67%上升至2017年52.83%,差异有统计学意义(χ^(2)=7.23,P=0.007)。微创手术患者百分比由2007年25.00%下降至2018年5.88%,分块切除手术患者百分比由2008年53.33%下降至2018年10.29%,两种手术方式占比呈显著下降趋势,差异有统计学意义(χ^(2)_(微创手术)=1.46,P_(微创手术)=0.026;χ^(2)_(分块切除)=19.56,P分块切除<0.001);分离手术患者百分比由2008年13.33%上升至2018年64.71%,整块切除手术患者百分比由2007年0上升至2018年10.29%,两种手术方式均呈现显著增长趋势,差异有统计学意义(χ^(2)_(分离手术)=27.09,P分离手术<0.001;χ^(2)_(整块切除)=4.16,P_(整块切除)=0.042)。多元logistic回归分析显示年龄、转移部位、转移节段数量、椎体病理性骨折、Frankel分级、脊柱肿瘤不稳定评分(spinal instability neoplastic score,SINS)、疼痛视觉模拟评分(visual analogue score,VAS)是影响手术决策的独立因素(均P<0.05)。结论随年代不同,手术侵袭性和彻底性在增加,表现为分离手术和椎体整块切除手术患者百分比呈显著上升趋势;年龄、转移部位、转移节段数量、椎体病理性骨折、Frankel分级、SINS评分和VAS评分是影响手术决策的独立因素。

Objective To retrospectively analyze the patients with spinal metastases who received surgical intervention and summarize the evolution of their clinical and pathological characteristics and surgical methods.Methods The data of 703 patients with spinal metastases from January 2007 to December 2018 were collected retrospectively.There were 395 males(56.19%,395/703)and 308 females(43.81%,308/703)with an average age of 58.14±11.46 years(range 13-84 years).According to the degree of invasion and thoroughness of tumor resection,the surgical methods could be divided into minimally invasive surgery,decompression surgery,separation surgery,piecemeal resection and total en-bloc spondylectomy surgery.The operative methods were minimally invasive surgery in 89 cases(12.66%),decompression surgery in 96 cases(13.66%),separation surgery in 303 cases(43.10%),piecemeal resection in 182 cases(25.89%)and total en-bloc spondylectomy in 33 cases(4.69%).To analyze the trend of the clinical,pathological types and surgical treatment of patients with spinal metastases over the years,and determine the relevant factors affecting the decision-making of surgical methods by multivariate logistic regression.Results The ratio of male to female was 1.28:1.39.54%(278/703)of patients with single-segment involvement in 703 patients,24.04%(169/703)of patients with double-segment metastasis and 36.42%(256/703)of patients with multi-segment metastasis.The most common type of primary tumor was lung cancer(34.57%,243/703),followed by breast cancer(8.25%,58/703),myeloma(8.11%,57/703),gastrointestinal tumor(6.82%,48/703)and renal malignant tumor(6.40%,45/703).From 2007 to 2018,there was no significant difference in the percentage change of different age,gender and primary tumor source composition(age:χ^(2)=14.01,P=0.233;gender:χ^(2)=35.73,P=0.341;primary tumor:χ^(2)=120.09,P=0.074).The percentage of patients with sacrococcygeal metastasis decreased from 20.00%in 2008 to 1.89%in 2017 and the difference was statistically significant(χ^(2)=8.09,P=0.005).The percentage of patients with multi-level metastasis increased from 26.67%in 2008 to 52.83%in 2017,and the difference was statistically significant(χ^(2)=7.23,P=0.007).The percentage of patients with minimally invasive surgery decreased from 25.00%in 2007 to 5.88%in 2018,and the percentage of patients with segmented resection decreased from 53.33%in 2008 to 10.29%in 2018.The proportion of the two surgical methods showed a significant downward trend,and the differences were statistically significant(minimally invasive surgery:χ^(2)=1.46,P=0.026;segmented resection surgery:χ^(2)=19.56,P<0.001).The percentage of patients undergoing separation surgery increased from 13.33%in 2008 to 64.71%in 2018,and the proportion of patients undergoing total en-bloc spondylectomy increased from 0 in 2007 to 10.29%in 2018.Both surgical methods showed a significant growth trend and the differences were statistically significant(separation surgery:χ^(2)=27.09,P<0.001;χ^(2)=4.16,P=0.042).Multivariate Logistic regression analysis showed that age,metastatic site,number of metastatic segments,pathological vertebral fractures,Frankel grade,SINS score and VAS score were independent factors influencing surgical decision-making(P<0.05).Conclusion With different time and age,the invasiveness and thoroughness of surgery are increasing,which shows that the percentage of patients who underwent separation surgery and to-tal en-bloc spondylectomy is significantly increasing.Age,metastatic site,number of metastatic segments,pathological vertebral fractures,Frankel grade,SINS score and VAS score are independent factors affecting surgical decision-making.