Klein Lukas, Herget Georg W, Ihorst Gabriele, Lang Gernot, Schmal Hagen, Hubbe Ulrich
Department of Orthopedics and Trauma Surgery, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany.
Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany.
J Clin Med. 2023 Feb 1;12(3):1167. doi: 10.3390/jcm12031167.
Currently, there is uncertainty about the predictive factors for metastatic epidural spinal cord compression (MESCC) and consecutive symptomatology in tumor patients. Prognostic algorithms for identifying patients at risk for paralysis are missing. The influence of the pathologic fracture on the patient's symptoms is widely discussed in the literature and we hypothesize that pathologic fractures contribute to spinal cord compression and are therefore predictive of severe paralysis. We tested this hypothesis in 136 patients who underwent surgery for spinal metastases. The most common primary cancers were prostate (24.3%, n = 33), breast (11.0%, n = 15), lung (10.3%, n = 14), and cancer of unknown primary (10.3%, n = 14). MESCC primarily affected the thoracic (77.2%, n = 105), followed by the lumbar (13.2%, n = 18) and cervical (9.6%, n = 13) spine. Pathologic fractures occurred in 63.2% (n = 86) of patients, mainly in osteolytic metastases. On the American spinal injury association (ASIA) impairment scale (AIS), 63.2% (n = 86) of patients exhibited AIS grade D and 36.8% (n = 50) AIS grade C-A preoperatively. The presence of a pathologic fracture alone did not predict severe paralysis (AIS C-A, = 0.583). However, the duration of sensorimotor impairments, patient age, spinal instability neoplastic score (SINS), and the epidural spinal cord compression (ESCC) grade together predicted severe paralysis ( = 0.006) as did the ESCC grade 3 alone ( = 0.028). This is in contrast to previous studies that stated no correlation between the degree of spinal cord compression and the severity of neurologic impairments. Furthermore, the high percentage of pathologic fractures found in this study is above previously reported incidences. The risk factors identified can help to predict the development of paralysis and assist in the improvement of follow-up algorithms and the timing of therapeutic interventions.
目前，肿瘤患者发生转移性硬膜外脊髓压迫（MESCC）及后续症状的预测因素尚不确定。识别有瘫痪风险患者的预后算法也不存在。病理性骨折对患者症状的影响在文献中已有广泛讨论，我们推测病理性骨折会导致脊髓压迫，因此可预测严重瘫痪。我们在136例接受脊柱转移瘤手术的患者中验证了这一假设。最常见的原发癌为前列腺癌（24.3%，n = 33）、乳腺癌（11.0%，n = 15）、肺癌（10.3%，n = 14）和原发灶不明的癌症（10.3%，n = 14）。MESCC主要影响胸椎（77.2%，n = 105），其次是腰椎（13.2%，n = 18）和颈椎（9.6%，n = 13）。63.2%（n = 86）的患者发生病理性骨折，主要见于溶骨性转移。根据美国脊髓损伤协会（ASIA）损伤分级量表（AIS），术前63.2%（n = 86）的患者为AIS D级，36.8%（n = 50）为AIS C - A级。单纯病理性骨折的存在并不能预测严重瘫痪（AIS C - A，P = 0.583）。然而，感觉运动障碍持续时间、患者年龄、脊柱不稳定肿瘤评分（SINS）和硬膜外脊髓压迫（ESCC）分级共同可预测严重瘫痪（P = 0.006），单独ESCC 3级也可预测（P = 0.028）。这与之前表明脊髓压迫程度与神经功能障碍严重程度无相关性研究相反。此外，本研究中发现的病理性骨折高比例高于先前报道的发生率。所确定的风险因素有助于预测瘫痪的发生，并有助于改进随访算法和治疗干预时机。
