Die ventrale Spondylodese beim älteren Patienten – Overtreatment oder sinnvolle Therapieoption?

 

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Zusammenfassung

Hintergrund: Die Datenlage bezüglich der Morbidität sowie der mittelfristigen Ergebnisse nach ventraler thorakoskopischer Spondylodese (VTS) beim älteren Patienten ist limitiert. Methodik: 23 Patienten mit traumatischer Wirbelkörperfraktur des thorakolumbalen Übergangs wurden eingeschlossen. Ein Alter über 60 Jahre und die VTS-Versorgung waren Voraussetzungen. Das Durchschnittsalter betrug 65 Jahre. In 87 % der Fälle lag eine A-Verletzung vor. In 21 Fällen erfolgte ein dorsoventrales Vorgehen mit bisegmentaler Spondylodese. Durchschnittlich 3,9 Jahre postoperativ erfolgten radiologische Verlaufskontrollen sowie die Evaluation mit SF-36- (Short Form 36) und ODI- (Oswestry Disability Index) Scores. Ergebnisse: Bei 5 Patienten kam es zu pulmonalen Komplikationen. Der durchschnittliche Korrekturverlust betrug 3,2°. Bei 4 Patienten kam es intraoperativ zu einer Grund- bzw. Deckplattenläsion mit einhergehendem signifikant höherem Korrekturverlust (13,6° ± 4,5°; p < 0,001). Die Score-Ergebnisse von SF 36 und ODI zeigten keine signifikanten Unterschiede zum statistischen Vergleichskollektiv und nur geringe wirbelsäulenspezifische Einschränkungen. Schlussfolgerung: Die VTS scheint auch beim älteren Patienten eine sinnvolle Behandlungsstrategie darzustellen. Die exakte Präparation Grund-/Deckplatte scheint bez. der dauerhaften Herstellung des sagittalen Profils maßgeblich zu sein.

Abstract

Background: Only limited data are available concerning the effect of ventral thoracoscopic spondylodesis (VTS) on elderly patients and the medium-term outcome. Material and Method: In a retrospective study, 23 patients were included from 2003 to 2008. An age over 60, a traumatic burst fracture in the thoracolumbar region and a VTS procedure were inclusion criteria. A preoperative neurological deficit, ASA scores greater than 3 and a malignant disease were exclusion criteria. The mean age was 65 (62–70) years, 17 male and 6 female patients were included. In 87 % (n = 18) of the patients a compression fracture type A was found. Bone density values were obtained in 5 patients, mean value was −1,7. 21 patients were treated with a dorsoventral, bisegmental procedure. Two patients with limited kyphosis and no relevant stenosis of the spinal canal were treated with a ventral only procedure. In two cases with measured low bone quality, pedicle screws were placed with bone cement. Patients were monitored on ICU for 24 hours after operation until the thoracic drainage was removed. At an average follow-up of 3.9 years, patients were evaluated with SF 36 (short form 36) and an Oswestry disability index score (ODI score). The postoperative radiographic control was performed with a CT scan, X-ray controls were taken 3, 6, 12 and 18 months after the operation. Cobb angle and scoliosis angle were measured. Statistical analysis was carried out with SPSS-Software 17.0 (SPSS®, Inc., Chicago, USA) and a Mann-Whitney U test and a level of significance of p < 0,05. Results: In five patients pulmonary complications occurred, in one case a revision operation had to be performed due to pleural effusion. One patient suffered from a delayed pneumonia. The mean loss of correction in all patients was 3,3° (−20°–1°). In four patients with a distinct loss of correction at an average of 13,6° ± 4,5°, iatrogenic damage of the lower or upper cover plate of the adjacent vertebral bodies was found. The risk of loss of correction was found to be significantly higher in case of damage to the lower or upper cover plate (p < 0.001). Test results from the SF 36 score (sum scale 40.8) showed no significant difference in life quality to a similar aged comparison group. The ODI score revealed a mean vertebral column associated impairment of 10.8 %, 20 patients showed only minimal limitations. Conclusion: Also in older patients VTS seems to be an adequate treatment of traumatic burst fractures of the thoracolumbar spine. Perioperative pulmonary complications were easy to handle and had no effect on the clinical outcome. Postoperative radiographs showed only little loss of correction, in four cases iatrogenic damage of the cover-plate led to a distinct loss of correction. Careful and accurate preparation of the cover plates is therefore decisive.

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