Elder Benjamin D, Ishida Wataru, Goodwin C Rory, Bydon Ali, Gokaslan Ziya L, Sciubba Daniel M, Wolinsky Jean-Paul, Witham Timothy F
Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and.
Department of Neurosurgery, Brown University School of Medicine, Providence, Rhode Island.
Neurosurg Focus. 2017 Jan;42(1):E16. doi: 10.3171/2016.8.FOCUS16112.
OBJECTIVE With the advent of new adjunctive therapy, the overall survival of patients harboring spinal column tumors has improved. However, there is limited knowledge regarding the optimal bone graft options following resection of spinal column tumors, due to their relative rarity and because fusion outcomes in this cohort are affected by various factors, such as radiation therapy (RT) and chemotherapy. Furthermore, bone graft options are often limited following tumor resection because the use of local bone grafts and bone morphogenetic proteins (BMPs) are usually avoided in light of microscopic infiltration of tumors into local bone and potential carcinogenicity of BMP. The objective of this study was to review and meta-analyze the relevant clinical literature to provide further clinical insight regarding bone graft options. METHODS A web-based MEDLINE search was conducted in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, which yielded 27 articles with 383 patients. Information on baseline characteristics, tumor histology, adjunctive treatments, reconstruction methods, bone graft options, fusion rates, and time to fusion were collected. Pooled fusion rates (PFRs) and I values were calculated in meta-analysis. Meta-regression analyses were also performed if each variable appeared to affect fusion outcomes. Furthermore, data on 272 individual patients were available, which were additionally reviewed and statistically analyzed. RESULTS Overall, fusion rates varied widely from 36.0% to 100.0% due to both inter- and intrastudy heterogeneity, with a PFR of 85.7% (I = 36.4). The studies in which cages were filled with morselized iliac crest autogenic bone graft (ICABG) and/or other bone graft options were used for anterior fusion showed a significantly higher PFR of 92.8, compared with the other studies (83.3%, p = 0.04). In per-patient analysis, anterior plus posterior fusion resulted in a higher fusion rate than anterior fusion only (98.8% vs 86.4%, p < 0.001). Although unmodifiable, RT (90.3% vs 98.6%, p = 0.03) and lumbosacral tumors (74.6% vs 97.9%, p < 0.001) were associated with lower fusion rates in univariate analysis. The mean time to fusion was 5.4 ± 1.4 months (range 3-9 months), whereas 16 of 272 patients died before the confirmation of solid fusion with a mean survival of 3.1 ± 2.1 months (range 0.5-6 months). The average time to fusion of patients who received RT and chemotherapy were significantly longer than those who did not receive these adjunctive treatments (RT: 6.1 months vs 4.3 months, p < 0.001; chemotherapy: 6.0 months vs 4.3 months, p = 0.02). CONCLUSIONS Due to inter- and intrastudy heterogeneity in patient, disease, fusion criteria, and treatment characteristics, the optimal surgical techniques and factors predictive of fusion remain unclear. Clearly, future prospective, randomized studies will be necessary to better understand the issues surrounding bone graft selection following resection of spinal column tumors.
目的 随着新辅助治疗方法的出现，脊柱肿瘤患者的总生存率有所提高。然而，由于脊柱肿瘤相对罕见，且该队列中的融合结果受多种因素影响，如放射治疗（RT）和化疗，因此关于脊柱肿瘤切除术后最佳骨移植选择的知识有限。此外，肿瘤切除后骨移植选择通常有限，因为鉴于肿瘤向局部骨的微小浸润以及骨形态发生蛋白（BMP）的潜在致癌性，通常避免使用局部骨移植和BMP。本研究的目的是回顾和荟萃分析相关临床文献，以提供关于骨移植选择的进一步临床见解。方法 根据系统评价和荟萃分析的首选报告项目（PRISMA）指南进行基于网络的MEDLINE搜索，共获得27篇文章，涉及383例患者。收集了关于基线特征、肿瘤组织学、辅助治疗、重建方法、骨移植选择、融合率和融合时间的信息。在荟萃分析中计算合并融合率（PFRs）和I值。如果每个变量似乎影响融合结果，还进行了荟萃回归分析。此外，有272例个体患者的数据，对其进行了额外的回顾和统计分析。结果 总体而言，由于研究间和研究内的异质性，融合率差异很大，从36.0%到100.0%不等，PFR为85.7%（I = 36.4）。与其他研究（83.3%，p = 0.04）相比，使用碎块状自体髂嵴骨移植（ICABG）和/或其他骨移植选择进行前路融合的研究显示PFR显著更高，为92.8%。在个体患者分析中，前后路联合融合的融合率高于仅前路融合（98.8%对86.4%，p < 0.001）。在单因素分析中，虽然无法改变，但RT（90.3%对98.6%，p = 0.03）和腰骶部肿瘤（74.6%对97.9%，p < 0.001）与较低的融合率相关。平均融合时间为5.4±1.4个月（范围3 - 9个月）,而272例患者中有16例在确认牢固融合前死亡，平均生存期为3.1±2.1个月（范围0.5 - 6个月）。接受RT和化疗的患者的平均融合时间明显长于未接受这些辅助治疗的患者（RT：6.1个月对4.3个月，p < 0.001；化疗：6.0个月对4.3个月，p = 0.02）。结论 由于患者、疾病、融合标准和治疗特征方面的研究间和研究内异质性，最佳手术技术和预测融合的因素仍不明确。显然未来需要进行前瞻性、随机研究，以更好地了解脊柱肿瘤切除术后骨移植选择相关问题。
