Seegenschmiedt M H, Keilholz L
Department of Radiotherapy, University of Erlangen-Nuremberg, Erlangen, Germany.
Radiother Oncol. 1998 Apr;47(1):17-28. doi: 10.1016/s0167-8140(97)00182-5.
The effectiveness of radiotherapy (RT) for degenerative inflammatory disorders has been clinically documented in historical studies, but long-term follow-up and assessment with objective criteria are still not available.
From 1986 to 1991, 200 consecutive patients with symptomatic epicondylopathia humeri (EPH, n = 104) and peritendinitis humeroscapularis (PHS, n = 96) were referred to our clinic. All patients were refractory to conventional therapy prior to irradiation. One hundred fifty-six patients with 192 sites (due to bilateral symptoms) received a full treatment course and were available for long-term follow-up, i.e. 83 patients with 93 elbows and 73 patients with 89 shoulders. The treatment response was evaluated with regard to pain symptoms grouped into five categories (pain at strain, pain at night, persistent pain during daytime, pain at rest and morning stiffness) and four grades (none, mild, moderate and severe) and with regard to established orthopedic scores (Morrey score and Constant and Murley score). The analysis was performed before and 6 weeks after RT and at last follow-up. All joints received two RT series applied in three weekly fractions (EPH, 6 x 1 Gy (total 12 Gy); PHS, 6 x 0.5 Gy (total 6 Gy)). The second RT series started 6 weeks after the first RT series. The minimum follow-up was 1 year for both groups and the mean follow-up reached 4 years (range 1-8 years).
Fifty elbows (43 patients) and 44 shoulders (39 patients) achieved complete pain relief in all pain categories; 24 elbows and 28 shoulders substantially improved, i.e. had only minor symptoms. Thus, 74 elbows and 72 shoulders responded to RT. Nineteen elbows (17 patients) had surgery after RT due to persisting symptoms or subjective dissatisfaction; 17 shoulders (12 patients) were non-responders and five of those were operated on; seven elbows and one shoulder were completely free of pain after surgery. The mean Morrey score improved by 18 points (from 78 to 96) and the mean Constant and Murley score improved by 48 points (from 18 to 66). Two cases worsened according to the Morrey score and one case worsened according to the Constant and Murley score. Bi- and multivariate analysis revealed two factors with negative prognostic value on treatment outcome, i.e. EPH, long symptom interval prior to RT and long-term immobilization with plaster (P < 0.05) and PHS, long symptom interval prior to RT and lack of pain intensification during the first RT course (P < 0.05) were poor prognostic factors.
RT is highly effective for refractory EPH and PHS. Structured pain scores and quantitative orthopedic scores are important for evaluation. Prognostic factors for outcome can be established. Due to minimal side effects and low costs, RT represents an excellent treatment compared to conventional methods of treatment and surgery in the chronic disease.
放射治疗（RT）对退行性炎症性疾病的有效性在既往研究中已有临床记录，但仍缺乏长期随访及客观标准评估。
1986年至1991年，连续200例有症状的肱骨外上髁炎（EPH，n = 104）和肩袖肌腱炎（PHS，n = 96）患者被转诊至我院。所有患者在放疗前对传统治疗均无效。156例患者共192个部位（因双侧症状）接受了完整疗程治疗并可进行长期随访，即83例患者的93个肘部和73例患者的89个肩部。根据疼痛症状分为五类（用力时疼痛、夜间疼痛、白天持续性疼痛、休息时疼痛和晨僵）和四级（无、轻度、中度和重度）以及既定的骨科评分（Morrey评分和Constant及Murley评分）来评估治疗反应。分析在放疗前、放疗后6周及末次随访时进行。所有关节均接受两个放疗疗程，每周分三次给予（EPH，6×1 Gy（总计12 Gy）；PHS，6×0.5 Gy（总计6 Gy））。第二个放疗疗程在第一个放疗疗程后6周开始。两组的最短随访时间均为1年，平均随访时间达4年（范围1 - 8年）。
50个肘部（43例患者）和44个肩部（39例患者）所有疼痛类别均实现完全疼痛缓解；24个肘部和28个肩部有显著改善，即仅有轻微症状。因此，74个肘部和72个肩部对放疗有反应。19个肘部（17例患者）因症状持续或主观不满意在放疗后接受了手术；17个肩部（12例患者）无反应，其中5例接受了手术；7个肘部和1个肩部术后完全无痛。平均Morrey评分提高了18分（从78分提高到96分），平均Constant及Murley评分提高了48分（从18分提高到66分）。根据Morrey评分有2例病情恶化，根据Constant及Murley评分有1例病情恶化。双因素和多因素分析显示两个对治疗结果有负面预后价值的因素，即EPH、放疗前症状持续时间长和长期石膏固定（P < 0.05）以及PHS、放疗前症状持续时间长和第一个放疗疗程中无疼痛加剧（P < 0.05）是不良预后因素。
放疗对难治性EPH和PHS非常有效。结构化疼痛评分和定量骨科评分对评估很重要。可以确定预后因素。由于副作用极小且成本低，与传统治疗方法和手术相比，放疗在慢性病治疗中是一种极佳的治疗方法。
