Department of Orthopedic, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
Department of Orthopedic Oncology, Changzheng Hospital, Second Affiliated Hospital of Naval Medical University, Shanghai, 200003, China.
Eur Spine J. 2024 May;33(5):1868-1898. doi: 10.1007/s00586-023-08127-z. Epub 2024 Feb 26.
As an important treatment for spinal metastasis, surgery has strict applicable conditions. Although various organizations have formulated different guidelines on surgical treatment for spinal metastasis (SM), there are certain differences in the content, standardization and quality of the guidelines and it is necessary to make a critical appraisal of them. We aim to systematically review and appraise the current guidelines on surgical treatments of SM and summarize the related recommendations with the quality evaluation of supporting evidence, as to provide a reference for the standardization of surgical treatment plans, and help clinical front-line medical workers can make safe and effective clinical decisions faster.
We searched Pubmed, Web of Science, and Embase for three major databases and online guideline databases. According to certain inclusion and exclusion criteria, the latest guidelines on the surgical treatment of SM were sorted out. AGREE II was used to evaluated the guideline's quality, and we extracted and compared the recommended treatment content of each guideline with evaluating by the evidence-grading scale.
Eight guidelines from 2013 to 2019 were included. Seven guidelines are comprehensive guidelines and one related to the reconstructive surgery of SM. Five guidelines were evaluated as "recommended," and three guidelines were evaluated as "recommended with modifications." Regarding the indications of surgery with SM, four guidelines, seven guidelines, seven guidelines, three guidelines and three guidelines recommended surgical treatment for patients with SM with intractable pain, mechanical instability, metastatic epidural spinal cord compression (MESCC), recurrent spinal metastasis (RSM), and survival predication, respectively. Regarding the surgical strategies, three guidelines recommended minimally invasive therapy but had strict indications. Six guidelines and five guidelines recommend palliative surgery and with receiving radiation therapy, respectively. For the aggressive surgery, only one guideline recommended to apply to patients in good general conditions who has isolated symptomatic SM. Regarding the surgical reconstructions, one guideline didn't recommend iliac bone graft and three guidelines recommended PMMA bone cement.
Most of the guidelines do not provide clear criteria for surgical application and provide more of a basic framework. The level of evidence for these surgical recommendations ranges from LOE B to D, and almost all guidelines recommend vertebroplasty and kyphoplasty, but for palliative and more aggressive surgery, which recommended to personalize specific surgical strategies with multidisciplinary collaboration.
作为治疗脊柱转移瘤的重要手段，手术具有严格的适应证。尽管各种组织已经制定了脊柱转移瘤（SM）手术治疗的不同指南，但指南的内容、标准化和质量存在一定差异，有必要对其进行批判性评价。我们旨在系统地回顾和评价目前 SM 手术治疗指南，并总结相关建议，同时对证据质量进行评估，为手术治疗方案的规范化提供参考，帮助临床一线医务工作者更快地做出安全有效的临床决策。
我们检索了 Pubmed、Web of Science 和 Embase 三大数据库以及在线指南数据库，根据一定的纳入和排除标准，整理出最新的 SM 手术治疗指南。使用 AGREE II 评价指南的质量，并通过证据分级量表提取和比较各指南的推荐治疗内容。
纳入 2013 年至 2019 年的 8 项指南。7 项为综合性指南，1 项与 SM 重建手术相关。5 项被评为“推荐”，3 项被评为“推荐有修改”。关于 SM 手术适应证，4 项指南、7 项指南、7 项指南、3 项指南和 3 项指南分别推荐对 SM 患者伴有难治性疼痛、机械性不稳定、转移性硬膜外脊髓压迫（MESCC）、复发性脊柱转移（RSM）和生存预测的患者进行手术治疗。关于手术策略，3 项指南推荐微创治疗，但有严格的适应证。6 项指南和 5 项指南分别推荐姑息性手术和接受放射治疗。对于积极的手术，只有一项指南建议应用于一般情况良好且仅有症状性 SM 的患者。关于手术重建，1 项指南不建议使用髂骨移植物，3 项指南建议使用 PMMA 骨水泥。
大多数指南并未为手术应用提供明确的标准，而是提供了更基本的框架。这些手术建议的证据水平从 LOE B 到 D 不等，几乎所有指南都推荐使用椎体成形术和后凸成形术，但对于姑息性和更积极的手术，建议与多学科合作制定个性化的具体手术策略。
