李福生 徐紹年 杜振廣 王亮 黃?!±罟鈳?/p>
[摘要]目的 探討經(jīng)皮骨水泥髖臼成形術(shù)在髖臼溶骨性轉(zhuǎn)移瘤中的臨床應(yīng)用價(jià)值。方法 回顧性分析2012年1月~2016年12月我院收治的6例行DSA引導(dǎo)下經(jīng)皮骨水泥髖臼成形術(shù)患者的臨床資料,比較手術(shù)前后的數(shù)字等級(jí)量表(NRS)評(píng)分和行走功能評(píng)分,并計(jì)算術(shù)后1周、術(shù)后1、3個(gè)月的疼痛緩解率和行走功能改善率,術(shù)后3個(gè)月復(fù)查CT進(jìn)行病灶控制情況的評(píng)估。結(jié)果 6例患者均完成髖臼成形術(shù)?;颊咝g(shù)后1周、術(shù)后1、3個(gè)月的NRS評(píng)分均低于術(shù)前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);術(shù)后1周、術(shù)后1、3個(gè)月的疼痛緩解率分別為100.0%、83.3%、83.3%?;颊咝g(shù)后1周、術(shù)后1、3個(gè)月的行走功能評(píng)分均高于術(shù)前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);術(shù)后1周、術(shù)后1、3個(gè)月的行走功能改善率分別為83.3%、66.7%、66.7%。術(shù)后3個(gè)月復(fù)查CT,病灶無(wú)變化5例(83.3%),進(jìn)展1例(16.7%)。1例患者術(shù)中發(fā)生骨水泥滲漏,發(fā)生率為16.7%,對(duì)髖關(guān)節(jié)功能無(wú)影響,所有患者均未發(fā)生骨水泥肺栓塞等嚴(yán)重并發(fā)癥。結(jié)論 經(jīng)皮骨水泥髖臼成形術(shù)可有效緩解髖臼溶骨性轉(zhuǎn)移瘤引起的疼痛并改善行走功能,在術(shù)后3個(gè)月內(nèi)可維持一個(gè)比較穩(wěn)定的狀態(tài),手術(shù)并發(fā)癥發(fā)生率較低,是一種安全有效、微創(chuàng)的治療方法。
[關(guān)鍵詞]骨水泥;髖臼成形術(shù);骨轉(zhuǎn)移瘤;溶骨性
[中圖分類號(hào)] R73? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] A? ? ? ? ? [文章編號(hào)] 1674-4721(2019)10(a)-0140-03
[Abstract] Objective To explore the clinical application value of percutaneous cemented acetabular plasty in the treatment of acetabular osteolytic metastases. Methods A retrospective analysis was made of the clinical data of 6 patients who underwent DSA-guided percutaneous cemented acetabular plasty from January 2012 to December 2016. The scores of NRS and walking function before and after operation were compared. The pain relief rate and walking function improvement rate at 1 week, 1 month and 3 months after operation were calculated. The focus control was evaluated by CT at 3 months after operation. Results Acetabuloplasty was performed in all 6 patients. The NRS scores of 1 week, 1 month and 3 months after operation were lower than those before operation, the differences were statistically significant (P<0.05). The pain relief rates were 100.0%, 83.3% and 83.3% in 1 week, 1 month and 3 months after operation, respectively. The walking function scores of 1 week, 1 month and 3 months after operation were higher than those before operation, the differences were statistically significant (P<0.05). The improvement rates of walking function were 83.3%, 66.7% and 66.7% at 1 week, 1 month and 3 months after operation, respectively. Three months after operation, CT showed no change in 5 cases (83.3%) and progress in 1 case (16.7%). The incidence of cement leakage was 16.7%. There was no effect on hip function. No serious complications such as cement pulmonary embolism occurred in all patients. Conclusion Percutaneous cemented acetabular plasty can effectively relieve pain caused by acetabular osteolytic metastases and improve walking function. It can maintain a relatively stable state within 3 months after operation. The incidence of surgical complications is low. It is a safe, effective and minimally invasive treatment.
[Key words] Bone cement; Acetabular plasty; Bone Metastasis; Osteolytic
大約惡性腫瘤80%會(huì)發(fā)生骨轉(zhuǎn)移,髖臼是好發(fā)部位之一。髖臼溶骨性轉(zhuǎn)移瘤較常見(jiàn),腫瘤會(huì)造成患者劇烈的疼痛和行走功能障礙,在病變的早期即具有一定的致殘性[1-2]。髖臼部位解剖復(fù)雜、手術(shù)風(fēng)險(xiǎn)高,且腫瘤發(fā)生髖臼轉(zhuǎn)移時(shí)常伴有其他部位的轉(zhuǎn)移,對(duì)于不適合傳統(tǒng)手術(shù)的病例,臨床上需要一種能有效緩解疼痛改善患者行走功能的治療方法。經(jīng)皮骨水泥髖臼成形術(shù)是微創(chuàng)治療髖臼轉(zhuǎn)移瘤中的一種,是“經(jīng)皮椎體成形術(shù)”“骨成形術(shù)”等技術(shù)的延伸[3-6],本研究旨在探討經(jīng)皮骨水泥髖臼成形術(shù)在髖臼溶骨性轉(zhuǎn)移瘤中的臨床應(yīng)用價(jià)值,現(xiàn)報(bào)道如下。
1資料與方法
1.1一般資料
回顧性分析2012年1月~2016年12月我院收治的6例行DSA引導(dǎo)下經(jīng)皮骨水泥髖臼成形術(shù)患者的臨床資料,其中男4例,女2例;年齡45~81歲,平均(64.0±16.0)歲;隨訪時(shí)間4~21個(gè)月,平均(13.5±6.4)個(gè)月;原發(fā)腫瘤為肺癌3例,腎癌2例,前列腺癌1例。術(shù)前患者均接受過(guò)化療或靶向及內(nèi)分泌治療,未接受過(guò)局部放療,術(shù)后均繼續(xù)進(jìn)行靶向藥物或內(nèi)分泌等輔助治療。
納入標(biāo)準(zhǔn):①原發(fā)惡性腫瘤經(jīng)病理學(xué)證實(shí),非孤立性髖臼轉(zhuǎn)移者;②持續(xù)性疼痛,保守治療后無(wú)明顯改善者;③預(yù)期生存時(shí)間≥3個(gè)月者;④不能手術(shù)或不愿手術(shù)者;⑤血常規(guī)、凝血功能、肝功能、腎功能、心功能基本正常者。排除標(biāo)準(zhǔn)[5]:①成骨性轉(zhuǎn)移者;②存在嚴(yán)重出血傾向者;③嚴(yán)重心、肝、腎衰竭患者。
1.2手術(shù)方法
術(shù)前完善血常規(guī)、肝腎功能、凝血功能、心電圖等常規(guī)檢查,根據(jù)骨盆DR、CT、MRI進(jìn)行手術(shù)規(guī)劃?;颊呷「┡P或仰臥位,常規(guī)消毒鋪無(wú)菌單,DSA引導(dǎo)下在擬穿刺點(diǎn)及進(jìn)針?lè)较蛞?%利多卡因(山東華魯制藥有限公司,批號(hào):C1903053-2)局部浸潤(rùn)麻醉,麻醉后以骨穿刺針穿刺至病灶中心偏向內(nèi)側(cè)后拔出針芯,以骨水泥注入系統(tǒng)緩慢注入骨水泥,注入量至少需充填病灶長(zhǎng)軸的75%,根據(jù)骨水泥分布情況適當(dāng)外拔或插入穿刺針,注入結(jié)束后需將針芯插入穿刺套筒,待骨水泥凝固后拔出穿刺針。如骨水泥有向髖關(guān)節(jié)面方向滲漏跡象立即停止注射,邊拔出穿刺套筒邊插入針芯,確保套筒退出外層骨皮質(zhì)時(shí)針芯已徹底插入,同時(shí)活動(dòng)髖關(guān)節(jié)3~5次。術(shù)后穿刺部位消毒并適當(dāng)加壓包扎,常規(guī)抗炎止血對(duì)癥治療3 d,根據(jù)患者的疼痛情況按照三階梯止痛治療原則,調(diào)整止痛藥物治療。椎體成形注入系統(tǒng)、穿刺針及骨水泥均為美國(guó)史賽克公司生產(chǎn)。
1.3觀察指標(biāo)及評(píng)價(jià)標(biāo)準(zhǔn)
比較手術(shù)前后的數(shù)字等級(jí)量表(numerical rating scales,NRS)評(píng)分和行走功能評(píng)分,并計(jì)算術(shù)后1周、術(shù)后1、3個(gè)月的疼痛緩解率和行走功能改善率,術(shù)后3個(gè)月復(fù)查CT進(jìn)行病灶控制情況的評(píng)估。①采用NRS評(píng)分評(píng)價(jià)患者的疼痛情況,其中0分代表無(wú)痛,10分代表患者能想象的最劇烈的疼痛。②采用風(fēng)濕病學(xué)標(biāo)準(zhǔn)進(jìn)行下肢行走功能的評(píng)價(jià),0分:無(wú)法行走;1分:需應(yīng)用雙拐輔助行走;2分:需應(yīng)用單拐輔助行走;3分:不需借助拐杖行走,但有跛行;4分:行走功能正常。③對(duì)術(shù)后1周、術(shù)后1、3個(gè)月患者的疼痛情況及止痛藥物使用情況進(jìn)行詳細(xì)記錄,疼痛緩解率=疼痛緩解例數(shù)/總例數(shù)×100%。④行走功能改善率=行走功能改善例數(shù)/總例數(shù)×100%。⑤影像學(xué)評(píng)價(jià)標(biāo)準(zhǔn),局部控制:病灶不再擴(kuò)大,邊緣硬化;無(wú)變化:病灶未見(jiàn)明顯擴(kuò)大;進(jìn)展:病灶進(jìn)一步擴(kuò)大,骨質(zhì)破壞更加明顯。
1.4統(tǒng)計(jì)學(xué)方法
采用統(tǒng)計(jì)學(xué)軟件SPSS 22.0分析數(shù)據(jù),計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,采用t檢驗(yàn);計(jì)數(shù)資料以率表示,采用χ2檢驗(yàn),以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2結(jié)果
2.1完成情況
6例患者均按術(shù)前計(jì)劃完成經(jīng)皮骨水泥髖臼成形術(shù),骨水泥注入量為5~10 ml,平均(6.9±1.9)ml。
2.2患者手術(shù)前后NRS評(píng)分和行走功能評(píng)分的比較
患者術(shù)后1周、術(shù)后1、3個(gè)月的NRS評(píng)分均低于術(shù)前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05);患者術(shù)后1周、術(shù)后1、3個(gè)月的行走功能評(píng)分均高于術(shù)前,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)(表1)。
2.3術(shù)后1周、術(shù)后1、3個(gè)月的疼痛緩解和行走功能改善情況
術(shù)后1周、術(shù)后1、3個(gè)月的疼痛緩解率分別為100.0%(6/6)、83.3%(5/6)、83.3%(5/6),行走功能改善率分別為83.3%(5/6)、66.7%(4/6)、66.7%(4/6)。術(shù)后2例患者仍應(yīng)用鹽酸羥考酮緩釋片止痛治療,但用量較術(shù)前減少,其中1例在術(shù)后1個(gè)月因局部病灶進(jìn)展,藥物用量恢復(fù)術(shù)前水平,其余4例術(shù)后1周內(nèi)逐漸停用止痛藥物。術(shù)后3個(gè)月復(fù)查CT,病灶無(wú)變化5例(83.3%),進(jìn)展1例(16.7%)。
2.4并發(fā)癥發(fā)生情況
1例(16.7%)患者術(shù)中發(fā)生骨水泥向髖關(guān)節(jié)滲漏,經(jīng)處理后,髖關(guān)節(jié)功能未受影響。所有患者未出現(xiàn)骨水泥肺栓塞等嚴(yán)重并發(fā)癥。
3討論
因?yàn)榧t骨髓的血運(yùn)豐富,骨轉(zhuǎn)移瘤常發(fā)生在紅骨髓豐富的部位,如椎體、骨盆、長(zhǎng)骨的干骺端,約2/3的骨轉(zhuǎn)移發(fā)生在椎體外,髖臼是惡性腫瘤發(fā)生骨轉(zhuǎn)移的常見(jiàn)部位[7-8]。骨轉(zhuǎn)移瘤常引起疼痛、脊髓壓迫、病理性骨折、高鈣血癥等骨相關(guān)事件。發(fā)生在髖臼負(fù)重部位的溶骨性轉(zhuǎn)移,因?yàn)槟[瘤破壞骨質(zhì)后骨的強(qiáng)度下降,患者在病變的早期就會(huì)出現(xiàn)劇烈的疼痛和行走功能障礙,嚴(yán)重影響其生活質(zhì)量。對(duì)于此類患者治療的目標(biāo)是:控制疼痛、增加髖臼的機(jī)械強(qiáng)度及改善其行走功能[2,9]。目前對(duì)于骨轉(zhuǎn)移瘤除傳統(tǒng)的開(kāi)放性手術(shù)外,治療方法主要包括止痛藥物治療、雙磷酸鹽藥物治療、放療、化療、放射性核素治療、射頻消融術(shù)、冷凍消融術(shù)、微波消融術(shù)、125I放射粒子植入術(shù)、中醫(yī)藥治療等,每種方法都有其優(yōu)勢(shì)和局限性[10-12]。這些方法可以緩解疼痛、有的還可以在一定程度上控制腫瘤的進(jìn)展,但均無(wú)法即刻增加髖臼骨的機(jī)械強(qiáng)度。
經(jīng)皮骨水泥髖臼成形術(shù)可能是通過(guò)以下的機(jī)制進(jìn)行治療:①骨水泥聚合放熱時(shí),局部溫度可達(dá)70~74℃,可殺傷腫瘤細(xì)胞,減少炎性因子釋放同時(shí)使神經(jīng)纖維發(fā)生壞死而緩解疼痛;②骨水泥單體毒性對(duì)腫瘤細(xì)胞及痛覺(jué)神經(jīng)纖維具有毀損作用;③骨水泥滲入腫瘤組織內(nèi),破壞和阻隔其供養(yǎng)血管使部分腫瘤組織壞死;④骨水泥可加固髖臼,增加髖臼的穩(wěn)定性,并可以防止進(jìn)一步發(fā)生病理性骨折[13-14]。Cotton等[6]報(bào)道采用骨水泥成形術(shù)治療11例髖臼轉(zhuǎn)移瘤,術(shù)后4 d內(nèi)9例患者的疼痛消失,所有患者行走能力均改善。吳春根等[13]報(bào)道15例髖臼轉(zhuǎn)移瘤患者行骨水泥髖臼成形術(shù)后,疼痛緩解率為80%,所有病例行走功能均得到明顯改善。本研究中6例患者在術(shù)后1周內(nèi)可以停用或減量應(yīng)用止痛藥物,疼痛緩解率達(dá)到100.0%、行走功能改善率為83.3%,與上述兩項(xiàng)研究相近,提示骨水泥髖臼成形術(shù)可顯著緩解髖臼溶骨性轉(zhuǎn)移瘤患者的疼痛,減少毒麻藥物的用量并改善其行走功能。
術(shù)后3個(gè)月,1例(16.7%)患者因局部病灶進(jìn)展,疼痛加重,止痛藥物恢復(fù)術(shù)前用量,行走功能障礙較入院時(shí)加重,提示經(jīng)皮骨水泥髖臼成形術(shù)對(duì)控制局部腫瘤進(jìn)展的作用有限。為了更有效地控制腫瘤進(jìn)展,可將經(jīng)皮髖臼成形術(shù)與125I放射性粒子植入術(shù)、射頻消融術(shù)、冷凍消融術(shù)、微波治療等微創(chuàng)技術(shù)聯(lián)合應(yīng)用[11-12,15]。
Cotten等[6]認(rèn)為髖臼關(guān)節(jié)面缺損>5 mm是手術(shù)的禁忌證,因?yàn)轶y臼關(guān)節(jié)面缺損越大,骨水泥越容易滲漏至關(guān)節(jié)。本研究中1例患者髖臼關(guān)節(jié)面缺損達(dá)23 mm,術(shù)中注入骨水泥時(shí)發(fā)生向髖關(guān)節(jié)方向滲漏,術(shù)者及時(shí)停止注射并活動(dòng)髖關(guān)節(jié)至骨水泥凝固塑形,術(shù)后此患者的行走功能沒(méi)有因?yàn)楣撬嗟臐B漏而加重,反而得到了一定程度的改善。因此,對(duì)于髖臼關(guān)節(jié)面缺損>5 mm的病例應(yīng)慎重進(jìn)行髖臼成形術(shù),但不應(yīng)該被視為絕對(duì)的手術(shù)禁忌證。
綜上所述,經(jīng)皮骨水泥髖臼成形術(shù)可在短時(shí)間內(nèi)即刻緩解髖臼溶骨性轉(zhuǎn)移瘤引起的疼痛、改善髖關(guān)節(jié)功能,是一種安全有效的治療方法。但由于本研究納入病例少,隨訪時(shí)間較短,對(duì)于髖臼溶骨性轉(zhuǎn)移瘤應(yīng)用骨水泥髖臼成形術(shù)進(jìn)行治療時(shí),如何選擇合適的病例、手術(shù)操作技巧、具體療效和并發(fā)癥的情況還需進(jìn)一步的臨床評(píng)價(jià)。
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(收稿日期:2019-04-22? 本文編輯:劉克明)