Discuz!NT|BBS|论坛

注册

 

医库账号可直接登录
发新话题 回复该主题

病例漫谈101:需化疗的恶性肿瘤患者并发脊柱感染的早期手术干预:两份病例报告及文献回顾 [复制链接]

1#
银光图片

Introduction

Spinal infectionis a relatively rare condition and accountsfor 2–16.7 % of all cases of osteomyelitis. In developed countries, improved public hygiene has facilitated the control of spinal infections since the 1970s; however, several papers have warned that the incidence of spinal infections has recently been rising again.One of the factors behind this has been reported to be the increased number of immunocompromised hosts such as patients undergoing chemotherapy for malignancy.
引言

脊柱感染是一种比较罕见的病症,占骨髓炎患者总数的2~16.7%。自20世纪70年代以来,发达国家公共卫生领域的改善使得脊柱感染得到了更好的控制;然而,一些文章报道显示最近一段时间脊柱感染的发病率又呈现出了上升趋势。其原因之一已在文献中有所报道,即免疫力低下的患者人数正在增加,例如那些接受化疗的恶性肿瘤患者。


Recent advances in chemotherapy for various malignancies have contributed to the increased life expectancy of such patients; therefore, prompt chemotherapy is required as soonas a patient is diagnosed as having malignancy. If such a patient has aconcurrent infection, his/her oncologist would hesitate to perform prompt chemotherapy owing to the risk of inducing sepsis, since the management ofsepsis would be extremely difficult for a patient undergoing chemotherapy. Therefore, the treatment of infection would have priority over initiating chemotherapy for the malignancy.

恶性肿瘤的化疗已有许多进展,这些新进展延长了患者的寿命;因此,当患者一旦被诊断为恶性肿瘤,则需立即进行化疗。如果这些患者同时并发感染性疾病,肿瘤科医生会犹豫是否要立即实施化疗,因为会有诱发脓毒症的风险。而对于化疗患者,脓毒症的治疗是非常困难的。因此,对于这样的恶性肿瘤患者,治疗感染总是优先于化疗。


Surgery for spinal infection is generally indicated under the following situations: (1) in cases demonstrating spinal cord compression causing a neurological deficit; (2)in cases with significant deformity or with significant vertebral body destruction; (3) in cases refractory to prolonged nonsurgical treatment; (4)when a clinically significant abscess is present; and (5) to obtain a bacteriologic diagnosis when closed biopsy is negative. When nonsurgical treatment is selected, prolonged antibiotic therapy is recommended. However, there is noguarantee that a patient will be cured by nonsurgical treatment.

出现下列情况时需考虑通过手术治疗脊柱感染:(1)脊髓压迫引起神经功能缺损;(2)明显的畸形或椎体受损;(3)经长期非手术治疗仍未治愈;(4)出现明显脓肿这一临床表现;(5)闭式活检的细菌学诊断为阴性。当采取非手术方式进行治疗时,建议患者接受长期的抗生素治疗。然而,这并不能保证脊柱感染患者通过非手术性治疗能够治愈。


We encountered two patients with malignancy requiring chemotherapy, who also demonstrated spinal infection, and performed early surgical intervention to avoid excessive delay in initiating chemotherapy.

我们遇到了2例需化疗的恶性肿瘤患者,他们均出现了脊柱感染,并且进行了早期手术干预以避免过度延误首次化疗。  


Case reports

Case 1

A 69-year-old female was transferred to our hospital for possible surgical intervention for spinal infection. She first experienced lower back pain 5 months before transferring to our hospital, and then, her symptom deteriorated. She was taking acarbose for type 2 diabetes mellitus (DM). Imaging studies at a local hospital demonstrated vertebral body destruction of L3 and L4 (Fig. 1a, b) and abnormal mass of the right lung. She was transferred to the previous hospital 1 month before transferring to our hospital and diagnosed pathologically as having malignant lymphoma (diffuse large B cell lymphoma) of the right lung.Mycobacterium tuberculosis was detected from a specimen obtained at the L3–4 disk.
病例报告

病例1

1例69岁的女性患者因脊柱感染被送至我们医院,希望进行可能的手术干预。在转移至我们医院前5个月,患者下背部首次出现了疼痛,之后症状出现了恶化。她一直在服用阿卡波糖以治疗II型糖尿病(DM)。当地医院的影像学研究显示L3和L4椎体有所受损(图1a,b),右肺存在异常肿块。患者被转送至我们医院前1个月就诊于这家医院,并诊断为右肺恶性淋巴瘤(弥漫性大细胞淋巴瘤)。结核杆菌在患者L3–4间盘样本中检出。


We were requested to perform early surgical intervention for spinal infection because prompt chemotherapy was required for malignant lymphoma. She underwent anterior debridement and interbody fusion between L3 and L4 with autogenous iliac graft combined with posterior fixation between L1 and L5 (Fig. 1c). Since there was apossibility that infection would recur under myelosuppression after the introduction of chemotherapy, we did not place pedicle screws into the involved vertebrae. Semi-hard thoracolumbo-sacral orthosis (TLSO) was applied for 3 months. Thirteen days after surgery, she was transferred back to the previous hospital for chemotherapy. Four years after surgery, the patient died of malignant lymphoma.

我们必须实施早期手术干预治疗脊髓感染,因为恶性淋巴瘤需要及时进行化疗。患者行前路病灶清除术、L3-L4之间行植骨融合术、同时行自体髂骨植骨术联合L1-L5之间后路固定术(图1c)。引入化疗后的骨髓抑制可能会出现感染,因此,我们没有在相应椎体处安置椎弓根螺钉。但让患者佩戴了3个月的半硬质胸腰骶支具(TLSO)。术后13天,患者被转移到了之前那家医院接受了化疗。术后四年,患者死于恶性淋巴瘤。


Fig. 1 Case 1 MRIwith gadolinium enhancement before surgery (a) and sagittalreconstruction CT (b) taken at a local hospital demonstrated vertebral bodydestruction of L3 and L4. A plain lateral film taken one year after surgery cshowed anterior interbody fusion between L3 and L4 with autogenous iliac graftcombined with posterior fixation between L1 and L5
图.1病例1在当地医院进行的术前钆增强MRI(a)和矢状位重建CT(b)检查证实L3和L4椎体受损。术后一年的侧位平片(c)显示L3和L4之间采取了前路椎间融合术,L1和L5之间实施了自体髂骨植骨术和固定术


Case 2
病例
2

A 66-year-old male was referred to our department from the Department of Gas troenterological Surgery in our hospital owing to spinal infection. He was on insulin injections for type 2 DM. Eight months before this consultation, he was diagnosed as having esophageal cancer (squamous cell cancer: cT4N0M0) and then received definitive chemoradiotherapy. This regime was effective and his cancer had disappeared on radiology. Thereafter, he had to continue receiving chemotherapy regularly, and the next chemotherapy was planned to be initiated soon. His laboratory data did not show any myelosuppression. Imaging studies demonstrated vertebral body destruction of L2 and L3, epidural abscess, and involvement ofthe posterior segment (Fig. 2a, b). The specimen obtained at L2–3 disk by computed tomography-guided biopsy demonstrated Staphylococcus aureus.

一例66岁男性患者,因脊髓感染由我院胃肠外科转移到了我们科室。因患II型糖尿病患者一直注射胰岛素。此次咨询前八个月,患者被诊断为食管癌(鳞状细胞癌:cT4N0M0),之后接受了针对性放化疗。这个疗法是有效的,通过放射治疗患者癌症逐渐消失。此后,患者定期接受化疗,下一次化疗按计划将很快启动。患者检验数据没有显示任何骨髓抑制现象。影像学研究显示L2和L3椎体有所受损,硬膜外脓肿,同时后段受累(图2 2a,b)。通过计算机断层扫描引导于L2-3间盘实施活检证实为金黄色葡萄球菌感染。


We were requested to cure spinal infection as soon as possible. However, his infection had spread to all three columns, and there was a concern that instability would occur even after rigid immobilization. Moreover, there was no guarantee that the spinal infection would be controlled nonsurgically. Therefore, we performed anterior debridement and interbody fusion with autogenous iliac graft between L2 and L3, and posterior debridement and bone graft (Fig. 2c). Since there was a possibility that infection would recur under myelosuppression after the introduction of chemotherapy for this patient, with both anterior and posterior involvements, we did not apply any instrumentation. Semi-hard TLSO was applied for 1 year. Four years after surgery, the patient is still alive and hasremained disease-free. Furthermore, he can walk without any assistance.

这要求我们尽快治疗脊柱感染。然而,感染已扩散至患者的三节脊柱,我们还担心即使进行了刚性固定仍会出现不稳定现象。此外,我们不能保证非手术治疗能控制脊柱感染。因此,我们行前路病灶清除术、L3-L4之间行植骨融合术、同时行后路病灶清除及植骨术(图2c)。患者接受化疗后的骨髓抑制可能会引发感染,因此,我们在椎体前后均没有置入任何内固定。患者佩戴了1年的半硬质胸腰骶支具(TLSO)。术后4年,患者无病生存,且能在没有任何援助的情况下行走。  



Fig. 2 Case 2 MRI withgadolinium enhancement before surgery (a) and sagittal reconstruction CT (b)demonstrated vertebral body destruction of L2 and L3, epidural abscess, and theinvolvement of the posterior segment. A plain lateral film taken 3 years and 6months after surgery c showed that anterior interbody fusion was achievedbetween L2 and L3
图.2 病例2术前钆增强MRI(a)和矢状位重建CT(b)显示L2和L3椎体受损,硬膜外脓肿,后段受累。
术后3年6个月的侧位平片(c)显示L2和L3之间成功进行了前路植骨融合。


Discussion

Generally accepted risk factors for spinal infection are conditions of systemicimmunocompromise such as malignancy, DM, and long-term corticosteroid administration. Bone marrow from patients with malignancy undergoing chemotherapy often shows prolonged periods of drug-induced myelosuppression.Therefore, an oncologist would hesitate to perform prompt chemotherapy if apatient with malignancy had concurrent spinal infection. The first choice forspinal infection is nonsurgical treatment including the administration of antibiotics and immobilization. However, there is no guarantee that the spinal infection would be controlled after the completion of such prolonged antibiotic treatment.
讨论

人们普遍认为诱发脊髓感染的因素是机体免疫功能下降,如恶性肿瘤、糖尿病以及长期接受糖皮质激素治疗。恶性肿瘤患者接受化疗后,其骨髓通常会出现药物引起的长期骨髓抑制。因此,如果肿瘤患者同时并发脊髓感染,肿瘤医生会犹豫是否立即进行化疗。脊柱感染首选非手术治疗,包括抗生素和固定治疗。然而,通过这种长期抗生素治疗并不能保证能控制脊柱感染。


To ourknowledge, there have been no previous reports describing the necessity of surgery for spinal infection in a patient with malignancy requiring prompt chemotherapy. Our patients developed spinal infection before initiating chemotherapy, but there have been many reports on spinal infections during chemotherapy. All authors treated their patients nonsurgically probably because chemotherapy could lead to myelosuppression, which involves a risk of recurrent spinal infection or other infection after surgery. Most papers did not provide detailed information on the duration of antibiotic use or the duration of refraining from chemotherapy; however, some patients required antibiotics formore than 1 year. Moschettoni et al. reviewed spinal epidural abscess complicating chemotherapy in patients with leukemia. Their paper focused on infection developing after the introduction of chemotherapy, and they recommended that a spinal epidural abscess be surgically drained in all cases.Meanwhile, they indicated that standard guidelines for surgical management of these infections had not yet been identified. Generally, patients before initiating chemotherapy do not demonstrate myelosuppression; however, anterior debridement and fusion with autogenous iliac graft is a major invasive surgery compared with drainage of a spinal epidural abscess. Saving the life of apatient with malignancy would be difficult without prompt chemotherapy;therefore, early surgical intervention is an alternative option under such acondition after the assessment of the risks and benefits for a patient.

据我们所知,尚无文献提及需立即接受化疗的恶性肿瘤患者并发脊柱感染时,行手术治疗的必要性。此患者在首次化疗前已出现脊柱感染,但很多文献报道的是化疗期间才出现脊柱感染。这些医生都是以非手术方式对患者进行治疗,因为化疗会导致骨髓抑制,术后会有引发复发性脊髓感染或其他感染的风险。多数文献没有提及抗生素使用或避免化疗的详细时间信息;然而,一些患者接受了1年多的抗生素治疗。moschettoni等人总结回顾了以化疗方式治疗白血病的患者并发髓外硬膜外脓肿的病例。他们的文章关注于实施化疗后,患者受感染的发展情况。他们建议,在所有患脊髓硬膜外脓肿的病例中都要进行手术引流。与此同时,文章还指出针对这种感染的手术治疗标准指南尚未明确。一般来说,患者在初次化疗前不会出现骨髓抑制;然而,与脊柱硬膜外脓肿行引流术相比,前路病灶清除术与自体髂骨移植融合术则是一种主要表现为侵入性的手术。如果不及时化疗,要想挽救恶性肿瘤患者的生命是有难度的;因此,在评估风险与利益的前提下,对患者进行早期手术干预也许是另一种可选方式。


Choosing the treatment strategy for spinal infection in patients with malignancy is still challenging. Prolonged antibiotic treatment is required for spinal infection; however, there is no guarantee that the spinal infection would be controlled with such conservative treatment. Therefore, early surgical intervention wouldbe an alternative option for patients with malignancy before chemotherapy toavoid excessive delay in initiating chemotherapy.

恶性肿瘤患者并发脊柱感染选择何种治疗策略仍具有挑战性。脊柱感染需接受长期的抗生素治疗;然而,通过这种保守治疗方式并不能保证能控制脊柱感染。因此,为了不过度延误首次化疗,恶性肿瘤患者在化疗前进行早期手术干预将是一种可选方式。


由Medicool医库软件 王露黔 编译

原文来自 Eur JOrthop Surg Traumatol

最后编辑Wang Luqian 最后编辑于 2016-07-12 16:37:48
分享 转发
TOP
发新话题 回复该主题