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Minimalinvasive ventrale Zugänge zum lumbosakralen Übergang

Minimally Invasive Anterior Approaches to the Lumbosacral Junction

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Zusammenfassung

Operationsziel

Retro- oder transperitoneale, minimalinvasive ventrale Darstellung des lumbosakralen Überganges L5/S1 zur intervertebralen monosegmentalen rigiden (Cage, Knochenspan) oder dynamischen (Bandscheibenprothese) Stabilisierung.

Indikationen

Degenerative Disc Disease (DDD) mit oder ohne Bandscheibenvorfall. DDD mit translatorischer oder frontaler Instabilität. Degenerative oder isthmische Spondylolisthese. Degeneration von Anschlusssegmenten post fusionem. Failed Back Surgery Syndrome (Postdiskektomie, Pseudarthrose). Spinalstenose mit Segmentinstabilität. Spondylitis und Spondylodiszitis.

Kontraindikationen

Vorausgegangene Fusionsoperationen über einen transperitonealen Zugang. Adipositas permagna. Relativ: Vorausgegangene abdominelle oder gynäkologische Operationen. Aorta-Bifurkation und/oder Cava-Confluens unmittelbar vor L5/S1. Große prävertebrale Granulationsgewebsbildung oder Psoasabszess nach Infekten. Erkrankungen des Gastrointestinaltraktes.

Operationstechnik

Ventraler horizontaler oder vertikaler Mittellinienzugang über L5/S1 retroperitoneal oder transperitoneal über rechten oder linken Unterbauch. Retroperitoneale Technik: Medialisieren des Peritonealsackes nach kontralateral. Transperitoneale Technik: Mini-Laparotomie mit Durchqueren von Peritoneum viscerale und parietale und Lateralisieren der Darmkonvolute; dann jeweils Darstellen der anterolateralen Bandscheibenzirkumferenz L5/S1 und Lateralisieren der Gefäße. Diskektomie und Vorbereiten des Implantatlagers.

Weiterbehandlung

Funktionelle Nachbehandlung und Mobilisation ohne externe Ruhigstellung bei dynamischer Segmentversorgung mit Bandscheibenprothese; dreimonatige Korsettversorgung mit stabilisierender Rumpforthese bei dorsoventraler Spondylodese; keine Einschränkung von Gehen, Stehen oder Sitzen.

Ergebnisse

Von 01/2002 bis 12/2007 wurden 454 Patienten (248 weiblich, 206 männlich) mit einem Durchschnittalter von 47,3 Jahren (15,4–80,0 Jahre) über einen minimalinvasiven ventralen Zugang im lumbosakralen Übergang wegen unterschiedlicher Indikationen operiert. 251-mal implantierten wir eine Bandscheibenendoprothese, 203-mal fusionierten wir nach dorsaler Instrumentation mit Fixateur interne von ventral mit Cage, trikortikalem Beckenkammspan, Knochenersatzmaterialien wie Hydroxyapatit oder Bone-Morphogenetic-Protein (BMP). Zugangsbedingt kam es bei 0,5% der Patienten zu Gefäßverletzungen – v.a. der Vena iliaca communis links –, Verletzungen des Gastrointestinaltraktes sowie Urogenitaltraktes (Niere, Ureter, Blase) fanden sich nicht, ebenso unter Berücksichtigung der routinemäßigen Nachkontrollen (3, 6, 12 Monate postoperativ) keine Infektionen.

Abstract

Objective

Minimally invasive anterior preparation of the lumbosacral junction L5/S1 via a retro- or transperitoneal approach, possibility of intervertebral mono- or bisegmental rigid (cage, bone graft) or dynamic (disc arthroplasty) segmental stabilization.

Indications

Degenerative disc disease (DDD) with or without disc herniation. DDD with translatoric or frontal instability. Degenerative or isthmic spondylolisthesis. Adjacent segment degeneration post fusionem. Failed back surgery syndrome (post discectomy, non-union). Spinal stenosis with dynamic segmental instability. Spondylitis/spondylodiscitis.

Contraindications

Previous transperitoneal lumbar fusion surgery. Adipositas permagna. Relative: Previous abdominal or gynaecological surgery. Aorta bifurcation and/or venous confluens directly in front of the lumbosacral disc space. Inflammation with large prevertebral granulation tissue formation or psoas abscess. Diseases of the gastrointestinal tract.

Surgical Technique

Anterior horizontal or vertical midline incision over L5/S1. Retroperitoneal or transperitoneal approach via the left or right lower abdomen. Retroperitoneal technique: medialization of the peritoneal sack towards the contralateral side. Transperitoneal technique: mini laparatomy, dissection of the visceral and parietal peritoneum and mobilization of the bowels laterally. Preparation of the anterolateral circumference of the L5/S1 disc space and mobilization of the vessels laterally. Discectomy and preparation of graft bed.

Postoperative Management

Functional postoperative care with mobilisation without external support following total lumbar disc replacement; stable trunk brace for 12 weeks in the case of fusion surgeries; no restrictions for standing, walking or sitting.

Results

Between January 2002 and December 2007, 454 patients (248 female, 206 male, average age 47.3 years, range between 15.4 years and 80.0 years,) underwent anterior surgery in the lumbosacral segment using a minimally invasive anterior approach. The spectrum of indications included monosegmental disc degeneration, spinal stenosis with segmental instability, isthmic oder degenerative spondylolisthesis, spondylodiscitis and others. Dynamic segmental support using total lumbar disc replacement was performed in 251 cases. Rigid stabilization with combined posterior internal fixation and anterior interbody fusion was performed in 203 cases (alternatively cage, tricortical iliac crest bone graft, bone substitutes such as hydroxyapatite or bone morphogenetic protein [BMP]). Approach-related, vascular complications occurred in 0.5 % (mainly left common iliac vein). Injuries of the gastrointestinal tract or urogenital tract (kidney, ureter, bladder) did not occur and there were no infections.

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Authors and Affiliations

  1. Wirbelsäulenzentrum, Schön Klinik München Harlaching, München, Germany

    Andreas Korge, Christoph Siepe, Christoph Mehren & H. Michael Mayer

  2. Wirbelsäulenzentrum, Schön Klinik München Harlaching, Harlachinger Str. 51, 81547, München, Germany

    Andreas Korge

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  1. Andreas Korge
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  2. Christoph Siepe
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  3. Christoph Mehren
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  4. H. Michael Mayer
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Correspondence to Andreas Korge.

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Zeichner: Jörg Kühn, Heidelberg

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Korge, A., Siepe, C., Mehren, C. et al. Minimalinvasive ventrale Zugänge zum lumbosakralen Übergang. Orthop Traumatol 22, 582–592 (2010). https://doi.org/10.1007/s00064-010-8051-8

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  • DOI: https://doi.org/10.1007/s00064-010-8051-8

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