脊柱转移性疾病课件

metastaticspinedisease:EvolutionXUWENBINSIRRUNRUNSHAWHOSPITALmetastaticspinedisease:Evol1backgroundIntheUSA,nearly300000adultshaveosseousmetastaticdisease,withapproximately60%ofthemetastasesbeingspinalmetastases.Approximately10%ofpatientswithspinalmetastasesdevelopspinalcordcompression—asevereandoftenpermanentlydisablingconditionthatisanoncologicalemergency.Historically,spinalmetastaseshavebeentreatedwithinvasivesurgicalapproaches(eg,en-blocresection),orlow-dosepalliativeconventionalexternal-beamradiotherapy(EBRT),orboth.backgroundIntheUSA,nearly32脊柱转移性疾病课件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%胃肠道5%肾脏6%甲状腺3%男性：肺癌，前列腺癌，肾癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宫癌、甲状腺癌、结肠癌、胃癌。Primarysite乳腺22%男性：肺癌，前列腺癌，肾癌5Lifeexpectancy肺癌：术后4月结肠癌：7月肾癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲状腺癌：10年（80-95%）1年：48%5年：1.5%Lifeexpectancy肺癌：术后4月1年：48%6InvolvedsegmentAutopsystudieshavedemonstratedthelumbarspinetobemostcommonlyinvolved,followedbythethoracicandcervicalsegments.Clinically,symptomaticspinalmetastasesaremostoftenlocalizedtothethoracicspine(withspecialpredilectionforthesegmentsaboutT4andT11),followedbythelumbarandcervicalsegments.Thoracic70%Lumbar20%Cervical10%InvolvedsegmentAutopsystudie7metastasispathwayHematogenousmetastasis：Batson’svenousplexus，cancerembolusLymphaticmetastasisImplantationmetastasisCSFmetastasismetastasispathwayHematogenous8Clinicalmanifestation疼痛是最常见的症状，约有70%患者以疼痛起病。疼痛常逐渐变为持续性加剧，夜间痛明显，制动多无效。严重者止痛药无效。大约有50%的胸脊髓损害患者在脊髓压迫症状出现时即表现出神经根性疼痛。疼痛因病症部位不同而异。

由于转移瘤主要位于椎体，往往从前方压迫椎体束或前角细胞，故运动功能损害常先出现。与其他脊髓病损类似，括约肌功能损害常提示不良预后。以脊柱转移为首发症状的为10%。Clinicalmanifestation疼痛是最常见的症9RadiologicalexamX线平片是脊柱转移瘤诊断最基本的影像学检查方法，常表现为骨质疏松、溶骨性或硬化性改变，以椎弓根消失（猫头鹰眨眼征）、椎体塌陷较常见，椎间隙通常正常。博兰（Boland）等认为椎体的扁平压缩比楔形变更有意义。相比X线平片，核素全身骨扫描可提前3~6个月发现骨性损害，其灵敏度高达95%~97%,多表现为放射性浓聚，对可疑骨转移瘤患者应尽量作骨扫描检查。对于椎体破坏及椎旁、椎管内占位性病变，应用CT检查显示较清楚，但当病变较小、CT扫描层距较宽时，容易漏诊。对于软组织病变检查，MRI可提供比X线平片、同位素、CT等检查更精确的影像学信息。对于选择治疗方法、手术进路等都具有重要的实用价值。

RadiologicalexamX线平片是脊柱转移瘤诊断10脊柱转移性疾病课件11脊柱转移性疾病课件12questionsGlobalperformancestatus?Lifeexpectancy?Mechanicalstableorunstable?Surgery,radiotherapy,orchemotherapy?Whensurgery?Radiotherapybeforeorafterthesurgery?Howlong?Medicinechoose,Steroidetc?questionsGlobalperformancest13脊柱转移性疾病课件14脊柱转移性疾病课件15KPS评分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评分References:

Crooks,V,Wa16ToMITa评分Tomita等对67例脊柱转移性肿瘤患者进行回顾性分析并总结制定新的预后评分系统，根据肿瘤恶性程度、脏器转移及骨转移情况进行评价，总分2~10分，根据不同评分指导选择不同治疗方案。前瞻性研究显示其预期生存时间和实际生存时间符合率为84%。注重预后，没有把神经压迫考虑进去。

ToMITa评分Tomita等对67例脊柱转移性肿瘤患者进行17Tomita评分Tomita评分18修正的Tokuhashi评分提示平均生存时间Zou等研究认为，修正的Tokuhashi评分系统对于短期预后的判断较为准确，而Tomita评分系统则更适用于长期预后结果的推测。ZouXN,GrejsA,LiHS,etal.Estimationoflifeexpectancyforselectingsurgicalprocedureandpredictingprognosisofextraduralspinalmetastases[J].AiZheng，2006，25(11):1406—1410.修正的Tokuhashi评分提示平均生存时间ZouXN,19脊柱转移性疾病课件20脊柱转移性疾病课件21脊柱转移性疾病课件22SINS系统：稳定性评估世界脊柱肿瘤研究小组（GSTSG）对SINS系统进行可信度及有效性分析，认为其预测准确性较好，灵敏度和特异度分别为95.7和79.52%。但SINS系统仅针对病灶局部稳定性进行评价，并未考虑患者全身情况，仅能用于制定局部治疗方案，无法对患者预后进行评估。SINS系统：稳定性评估世界脊柱肿瘤研究小组（GSTSG）对23Kostuik六柱理论：稳定性Kostuik的六柱理论经常用于评价脊柱的稳定性。kostuik分脊椎成六柱，包括椎体十字分割的四柱，和后部的两柱，并提出肿瘤占三柱或更多时会出现脊柱不稳，而当肿瘤累及五个或更多柱时，脊柱不稳更加严重。他还提出，椎体塌陷角为20°或更大时为脊柱不稳。这种分类是一种有用的准则，但也并非适用任何情况，因为有时肿瘤可能侵犯三或更多的部分，而不引起症状。1-2部分破坏属于稳定3-4部分破坏相对不稳5-6部分破坏绝对不稳

Kostuik六柱理论：稳定性Kostuik的六柱理论经常用24ESCC：Bilsky评分ESCC评分是用来详细描述硬膜或脊髓受压的程度。0级：指病变局限于骨内，无椎管内受累；1级：硬膜受压，脊髓未受压；2级：脊髓受压但仍可见脑脊液信号(MRI轴位T2加权图像)；3级：脊髓受压并且脑脊液信号中断。ESCC：Bilsky评分ESCC评分是用来详细描述硬膜或脊25ESCC：Bilsky评分ESCC：Bilsky评分26OncologicalparametersOncologicalparameters27脊柱转移性疾病课件28其他常见评分体系及分类Tomita评分（2009年）：基于预后分析改良Tokuhashi评分（2005年），Karnofsky评分Harrington评分：基于脊柱稳定性及神经功能脊柱肿瘤不稳定评分（SINS）Weinstein-Boriani-Biagini(WBB)分期：基于局部解剖结构Enneking分期Tomita分型其他常见评分体系及分类Tomita评分（2009年）：基于预29Harrington评分Harrington评分30Harrington评分Harrington早于1986年就根据脊柱稳定性破坏程度和神经功能状况对脊柱转移性肿瘤进行分类。哈林顿认为，1，2和3期应进行保守治疗，4或5期需要手术干预。3期的患者当神经系统可能进一步退化或瘫痪无改善的情况下，有时需接受手术治疗。因此，骨受累是评估手术指征的一个重要因素。该分类过于强调内科治疗的作用，对于放、化疗不敏感肿瘤，外科治疗的重要性并未突出，且分类过于简单，同一类别的患者预后可能存在极大差异，缺少临床指导意义，因此目前已很少使用。Harrington评分Harrington早于1986年就31Tomita分型根据肿瘤侵袭范围对脊柱转移性肿瘤进行分类，以指导手术方案选择。1-3型广泛切除或至少边缘切除，4-6型只有病灶周围存在纤维反应带时才能边缘切除。全脊柱整块切除手术适用于2-5型，1、6相对适应症，7禁忌症。

Tomita分型根据肿瘤侵袭范围对脊柱转移性肿瘤进行分类，32WBB分期1997年意大利的Boriani等人提出了胸腰椎的WBB脊柱肿瘤外科分期最初针对脊柱原发性肿瘤而创立，但目前亦应用于脊柱转移性肿瘤。该分期以脊髓为中心，按类似钟表表盘布局将椎体横断面分为12区，并根据解剖层次以硬膜囊及骨结构为边界将椎体及椎旁组织分为A~E层。WBB分期可清晰地显示肿瘤侵袭范围及脊髓压迫程度，为手术方案制定提供重要依据。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脊柱转移性疾病课件40separationsurgeryTheessentialelementsofmostseparationsurgeriesincludeposterolateraldecompressionviaalaminectomyandpedicleresection,withapartialcorpectomyoftheaffectedlevel.Thissurgerywilldestabilisethespine;thus,astabilisationprocedureisalwaysrequiredinconjunctionwiththetumourresection.DonnellyDJ,Abd-El-BarrMM,LuY.Minimallyinvasivemusclesparingposterior-onlyapproachforlumbarcircumferentialdecompressionandstabilizationtotreatspinemetastasis—technicalreport.WorldNeurosurg2015;84:1484–90.separationsurgeryTheessentia41脊柱转移性疾病课件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常见评分体系

的参考文献常见评分体系

的参考文献47Thankyou

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homemessage局部叩击痛、夜间痛、家族史，既往史，应警惕脊柱转移性肿瘤可能目前一般认为患者生存期>6周才有可能从稳定手术中获益，生存期>6个月的患者才考虑行脊柱肿瘤切除术。伴有背痛的MBD患者可能即将会发生MSCC而缓慢进展的瘫痪，数小时内发生的完全瘫痪和只有骨块压迫的MSCC患者是最有可能从手术中获益的人群。（肖建如）如果脊柱是稳定的(SINS0-6分)，脊柱肿瘤没有引起神经受压，多学科协作讨论后，根据肿瘤具体类型(例如乳腺癌、前列腺癌等放化疗敏感的肿瘤)可以先行放疗或化疗，以控制或减缓肿瘤进展。脊柱转移性肿瘤的诊断也须遵循临床、影像和病理三结合的原则。Takehomemessage局部叩击痛、夜间痛、家族史49Take

homemessage对于偶然发现、无明显症状的孤立性脊柱转移瘤，应先行放疗，如肿瘤增长较快，预计短期会发生病理骨折者，为避免脊髓在病理骨折时发生严重损伤，多建议手术治疗。多发脊柱转移瘤并非手术禁忌，笔者的经验是对引起神经症状的转移灶进行外科干预可取得较好的疗效。目前认为患者完全瘫痪大于48h术后恢复神经功能的可能性较低，是手术的相对禁忌证。预期生存期小于3个月的患者无法从手术中获益，是手术的禁忌证。术前放射治疗增加手术伤口不愈合的风险，而且这种风险与术前放疗的剂量和频次无关,已不再提倡。开放性手术一般于术后2~3周待伤口愈合后再进行放射治疗，而对于微创手术术后患者可立即接受放疗。Takehomemessage对于偶然发现、无明显症状的50metastaticspinedisease:EvolutionXUWENBINSIRRUNRUNSHAWHOSPITALmetastaticspinedisease:Evol51backgroundIntheUSA,nearly300000adultshaveosseousmetastaticdisease,withapproximately60%ofthemetastasesbeingspinalmetastases.Approximately10%ofpatientswithspinalmetastasesdevelopspinalcordcompression—asevereandoftenpermanentlydisablingconditionthatisanoncologicalemergency.Historically,spinalmetastaseshavebeentreatedwithinvasivesurgicalapproaches(eg,en-blocresection),orlow-dosepalliativeconventionalexternal-beamradiotherapy(EBRT),orboth.backgroundIntheUSA,nearly352脊柱转移性疾病课件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%胃肠道5%肾脏6%甲状腺3%男性：肺癌，前列腺癌，肾癌，肝癌，胃癌。女性：乳腺癌、肺癌、子宫癌、甲状腺癌、结肠癌、胃癌。Primarysite乳腺22%男性：肺癌，前列腺癌，肾癌55Lifeexpectancy肺癌：术后4月结肠癌：7月肾癌：11.3月前列腺癌：14月乳腺癌：21月肝癌：2年甲状腺癌：10年（80-95%）1年：48%5年：1.5%Lifeexpectancy肺癌：术后4月1年：48%56InvolvedsegmentAutopsystudieshavedemonstratedthelumbarspinetobemostcommonlyinvolved,followedbythethoracicandcervicalsegments.Clinically,symptomaticspinalmetastasesaremostoftenlocalizedtothethoracicspine(withspecialpredilectionforthesegmentsaboutT4andT11),followedbythelumbarandcervicalsegments.Thoracic70%Lumbar20%Cervical10%InvolvedsegmentAutopsystudie57metastasispathwayHematogenousmetastasis：Batson’svenousplexus，cancerembolusLymphaticmetastasisImplantationmetastasisCSFmetastasismetastasispathwayHematogenous58Clinicalmanifestation疼痛是最常见的症状，约有70%患者以疼痛起病。疼痛常逐渐变为持续性加剧，夜间痛明显，制动多无效。严重者止痛药无效。大约有50%的胸脊髓损害患者在脊髓压迫症状出现时即表现出神经根性疼痛。疼痛因病症部位不同而异。

由于转移瘤主要位于椎体，往往从前方压迫椎体束或前角细胞，故运动功能损害常先出现。与其他脊髓病损类似，括约肌功能损害常提示不良预后。以脊柱转移为首发症状的为10%。Clinicalmanifestation疼痛是最常见的症59RadiologicalexamX线平片是脊柱转移瘤诊断最基本的影像学检查方法，常表现为骨质疏松、溶骨性或硬化性改变，以椎弓根消失（猫头鹰眨眼征）、椎体塌陷较常见，椎间隙通常正常。博兰（Boland）等认为椎体的扁平压缩比楔形变更有意义。相比X线平片，核素全身骨扫描可提前3~6个月发现骨性损害，其灵敏度高达95%~97%,多表现为放射性浓聚，对可疑骨转移瘤患者应尽量作骨扫描检查。对于椎体破坏及椎旁、椎管内占位性病变，应用CT检查显示较清楚，但当病变较小、CT扫描层距较宽时，容易漏诊。对于软组织病变检查，MRI可提供比X线平片、同位素、CT等检查更精确的影像学信息。对于选择治疗方法、手术进路等都具有重要的实用价值。

RadiologicalexamX线平片是脊柱转移瘤诊断60脊柱转移性疾病课件61脊柱转移性疾病课件62questionsGlobalperformancestatus?Lifeexpectancy?Mechanicalstableorunstable?Surgery,radiotherapy,orchemotherapy?Whensurgery?Radiotherapybeforeorafterthesurgery?Howlong?Medicinechoose,Steroidetc?questionsGlobalperformancest63脊柱转移性疾病课件64脊柱转移性疾病课件65KPS评分References:

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Crooks,V,Wa66ToMITa评分Tomita等对67例脊柱转移性肿瘤患者进行回顾性分析并总结制定新的预后评分系统，根据肿瘤恶性程度、脏器转移及骨转移情况进行评价，总分2~10分，根据不同评分指导选择不同治疗方案。前瞻性研究显示其预期生存时间和实际生存时间符合率为84%。注重预后，没有把神经压迫考虑进去。

ToMITa评分Tomita等对67例脊柱转移性肿瘤患者进行67Tomita评分Tomita评分68修正的Tokuhashi评分提示平均生存时间Zou等研究认为，修正的Tokuhashi评分系统对于短期预后的判断较为准确，而Tomita评分系统则更适用于长期预后结果的推测。ZouXN,GrejsA,LiHS,etal.Estimationoflifeexpectancyforselectingsurgicalprocedureandpredictingprognosisofextraduralspinalmetastases[J].AiZheng，2006，25(11):1406—1410.修正的Tokuhashi评分提示平均生存时间ZouXN,69脊柱转移性疾病课件70脊柱转移性疾病课件71脊柱转移性疾病课件72SINS系统：稳定性评估世界脊柱肿瘤研究小组（GSTSG）对SINS系统进行可信度及有效性分析，认为其预测准确性较好，灵敏度和特异度分别为95.7和79.52%。但SINS系统仅针对病灶局部稳定性进行评价，并未考虑患者全身情况，仅能用于制定局部治疗方案，无法对患者预后进行评估。SINS系统：稳定性评估世界脊柱肿瘤研究小组（GSTSG）对73Kostuik六柱理论：稳定性Kostuik的六柱理论经常用于评价脊柱的稳定性。kostuik分脊椎成六柱，包括椎体十字分割的四柱，和后部的两柱，并提出肿瘤占三柱或更多时会出现脊柱不稳，而当肿瘤累及五个或更多柱时，脊柱不稳更加严重。他还提出，椎体塌陷角为20°或更大时为脊柱不稳。这种分类是一种有用的准则，但也并非适用任何情况，因为有时肿瘤可能侵犯三或更多的部分，而不引起症状。1-2部分破坏属于稳定3-4部分破坏相对不稳5-6部分破坏绝对不稳

Kostuik六柱理论：稳定性Kostuik的六柱理论经常用74ESCC：Bilsky评分ESCC评分是用来详细描述硬膜或脊髓受压的程度。0级：指病变局限于骨内，无椎管内受累；1级：硬膜受压，脊髓未受压；2级：脊髓受压但仍可见脑脊液信号(MRI轴位T2加权图像)；3级：脊髓受压并且脑脊液信号中断。ESCC：Bilsky评分ESCC评分是用来详细描述硬膜或脊75ESCC：Bilsky评分ESCC：Bilsky评分76OncologicalparametersOncologicalparameters77脊柱转移性疾病课件78其他常见评分体系及分类Tomita评分（2009年）：基于预后分析改良Tokuhashi评分（2005年），Karnofsky评分Harrington评分：基于脊柱稳定性及神经功能脊柱肿瘤不稳定评分（SINS）Weinstein-Boriani-Biagini(WBB)分期：基于局部解剖结构Enneking分期Tomita分型其他常见评分体系及分类Tomita评分（2009年）：基于预79Harrington评分Harrington评分80Harrington评分Harrington早于1986年就根据脊柱稳定性破坏程度和神经功能状况对脊柱转移性肿瘤进行分类。哈林顿认为，1，2和3期应进行保守治疗，4或5期需要手术干预。3期的患者当神经系统可能进一步退化或瘫痪无改善的情况下，有时需接受手术治疗。因此，骨受累是评估手术指征的一个重要因素。该分类过于强调内科治疗的作用，对于放、化疗不敏感肿瘤，外科治疗的重要性并未突出，且分类过于简单，同一类别的患者预后可能存在极大差异，缺少临床指导意义，因此目前已很少使用。Harrington评分Harrington早于1986年就81Tomita分型根据肿瘤侵袭范围对脊柱转移性肿瘤进行分类，以指导手术方案选择。1-3型广泛切除或至少边缘切除，4-6型只有病灶周围存在纤维反应带时才能边缘切除。全脊柱整块切除手术适用于2-5型，1、6相对适应症，7禁忌症。

Tomita分型根据肿瘤侵袭范围对脊柱转移性肿瘤进行分类，82WBB分期1997年意大利的Boriani等人提出了胸腰椎的WBB脊柱肿瘤外科分期最初针对脊柱原发性肿瘤而创立，但目前亦应用于脊柱转移性肿瘤。该分期以脊髓为中心，按类似钟表表盘布局将椎体横断面分为12区，并根据解剖层次以硬膜囊及骨结构为边界将椎体及椎旁组织分为A~E层。WBB分期可清晰地显示肿瘤侵袭范围及脊髓压迫程度，为手术方案制定提供重要依据。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脊柱转移性疾病课件90separationsurgeryTheessentialelementsofmostseparationsurgeriesincludeposterolateraldecompressionviaalaminectomyandpedicleresection,withapartialcorpectomyoftheaffectedlevel.Thissurgerywilldestabilisethespine;thus,astabilisationprocedureisalwaysrequiredinconjunctionwiththetumourresection.DonnellyDJ,Abd-El-BarrMM,LuY.Minimallyinvasivemusclesparingposterior-onlyapproachforlumbarcircumferentialdecompressionandstabilizationtotreatspinemetastasis—technicalreport.WorldNeurosurg2015;84:1484–90.separationsurgeryTheessentia91脊柱转移性疾病课件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