目的:恶性硬膜外脊髓压迫(MESCC),经常表现为背痛和运动/感觉缺陷,与不良生存有关,特别是在失去行走时。这篇综述的目的是评估文献,讨论MESCC的适当工作和管理,特别是在紧急情况下。
方法:对“脊髓压迫”和“放射治疗”进行了PubMed搜索。“为了这篇叙述性综述,对文章进行了分析。
■如果怀疑是MESCC,建议进行神经系统检查和完整的脊柱成像。如果有影像学证据表明高度压迫和/或临床上明显的运动缺陷,则需要紧急治疗。治疗涉及医疗管理的结合,手术减压,放射治疗(RT),和康复。对于运动缺陷,建议紧急开始高剂量类固醇。周向手术减压±稳定后再进行RT比单独进行RT具有更好的临床效果。对于手术不合理的患者,单独的RT可以提供显著的治疗反应,这取决于病理学的放射反应性。全身治疗,如果指示,通常保留到MESCC的初级治疗后,但是有化疗反应性肿瘤的患者可以接受初级化疗.选择的RT时间表应针对每位患者进行个性化设置,通常为10分(fx)30Gy,20Gyin5fx,或1fx中的8Gy。MESCC复发可以用额外的RT治疗,如果在脊髓耐受范围内,或手术。立体定向身体放射疗法(SBRT)已在一些中心用于神经功能相对完整的患者的高级MESCC,这些中心具有非常强大的基础设施,以支持在短时间内快速开始治疗。但对于大多数临床实践来说通常是不可行的。SBRT可能有利于低品位MESCC,复发,或在术后设置。在发生高级压迫或神经功能恶化之前检测MESCC可以使患者从先进的治疗中受益更多并改善预后。
结论:MESCC是一种破坏性疾病;最佳治疗应针对每位患者进行个性化治疗,并由多学科团队协作。
OBJECTIVE: Malignant epidural spinal cord compression (MESCC), often presenting with back pain and motor/sensory deficits, is associated with poor survival, particularly when there is loss of ambulation. The purpose of this review is to evaluate the literature and discuss appropriate workup and management of MESCC, specifically in the emergent setting.
METHODS: A PubMed search was conducted on \"spinal cord compression\" and \"radiation therapy.\" Articles were analyzed for the purpose of this narrative review.
UNASSIGNED: If MESCC is suspected, neurologic examination and complete spine imaging are recommended. Emergent treatment is indicated if there is radiographic evidence of high-grade compression and/or clinically significant motor deficits. Treatment involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation. For motor deficits, emergent initiation of high dose steroids is recommended. Circumferential surgical decompression ± stabilization followed by RT provides superior clinical outcomes than RT alone. For patients whom surgery is not reasonable, RT alone may provide significant treatment response which depends on radioresponsiveness of the pathology. Systemic therapy, if indicated, is typically reserved till after primary treatment of MESCC, but patients with chemoresponsive tumors may receive primary chemotherapy. The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions (fx), 20 Gy in 5 fx, or 8 Gy in 1 fx. MESCC recurrence may be treated with additional RT, if within the spinal cord tolerance, or surgery. Stereotactic body radiation therapy (SBRT) has been used for high grade MESCC in patients with relatively intact neurologic function at a few centers with a very robust infrastructure to support rapid initiation of treatment within a short period of time, but is generally not feasible for most clinical practices. SBRT may be advantageous for low grade MESCC, recurrence, or in the post-operative setting. Detection of MESCC prior to development of high-grade compression or deterioration of neurologic function may allow patients to benefit more from advanced therapies and improve prognosis.
CONCLUSIONS: MESCC is a devastating condition; optimal treatment should be personalized to each patient and approached collaboratively by a multidisciplinary team.