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Thorakoskopisches ventrales Release in Bauchlage simultan zur dorsalen Korrekturspondylodese

Wo sind die Grenzen?

Simultaneous thoracoscopically assisted anterior release in prone position and posterior scoliosis correction

What are the limits?

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Zusammenfassung

Hintergrund

Trotz des Einsatzes moderner pedikelschraubenbasierter Systeme bleibt die Korrektur rigider Rippenbuckel und Hypokyphosen ein Problem der allein von dorsal durchgeführten Skoliosechirurgie. Da es bis dato keine verlässliche Methode gibt, präoperativ das von dorsal erzielbare Korrekturausmaß der Rekyphosierung sowie der Apexderotation vorherzusagen, ist die Entscheidung, ob ein ventraler Zusatzeingriff zur Mobilisation notwendig ist, schwierig.

Methode

Mithilfe des thorakoskopisch assistierten Release in Bauchlage wird dieses Problem umgangen. Das Verfahren kann wie ein Zusatzmodul zur konventionellen Skoliosekorrektur von dorsal optional dann zum Einsatz kommen, wenn sich während des dorsalen Eingriffs zeigt, dass keine ausreichende Korrigierbarkeit erreicht werden kann.

Ergebnisse

Zwischen 1996 und 2005 wurden 161 Patienten (115 weiblich, 46 männlich) unter 30 Jahren, darunter 113 mit idiopathischer Skoliose, in Bauchlage simultan zur dorsalen Korrekturspondylodese thorakoskopisch mobilisiert. In Biportaltechnik wurden thorakoskopisch assistiert 131 Patienten von rechts und 30 Patienten von links versorgt, bei einer durchschnittlichen Operationszeit von 69 min und durchschnittlich 3,2 mobilisierten Segmenten. Bei 3 Patienten erfolgte eine zusätzliche retroperitoneoskopische Mobilisierung einer lumbalen rigiden Krümmung. In einer prospektiv ausgewerteten Subgruppe von 32 Patienten mit idiopathischer adoleszenter Skoliose liegt nach 10 Jahren die koronare Korrektur der Indexkrümmung bei 70 % (direkt postoperativ 75 %), die Kyphose Th5–Th12 ist mit 30° dauerhaft normalisiert und der Rippenbuckel auf 2,2 cm reduziert. Bei 23 von 32 Patienten musste die Gegenkrümmung nicht fusioniert werden. Die Versteifungsstrecke konnte in 13 Fällen bei Th12 oder höher enden und somit den thorakolumbalen Übergang weitgehend schonen. Leichte Komplikationen (Huang 1 oder 2) traten 4-mal auf; ein Hämatothorax erforderte die Ausräumung.

Schlussfolgerungen

Bei einer Distanz unter 25 mm zur Thoraxwand ist der Eingriff nicht möglich, sonstige Grenzen des Verfahrens oder Konversionen gab es nicht. Die Spätergebnisse nach 10–18 Jahren zeigen, dass der Mehraufwand eines zum dorsalen Standardeingriff simultanen thorakoskopischen ventralen Releases vertretbar und geeignet ist, bessere Korrekturergebnisse zu erreichen und dauerhaft zu erhalten.

Abstract

Background

In spite of modern pedicle-based systems, the correction of a rigid rib hump or hypokyphosis remains a problem in posterior-only scoliosis surgery. As there has so far been no reliable method of predicting the intraoperative extent of kyphosis restoration or rib hump correction by posterior-only surgery, it has been difficult to determine the indication for an additional anterior release.

Methods

The method described here circumvents this dilemma. Like an optional module, horacoscopically assisted release in prone position (TARP) can be added when it is obvious during posterior surgery that the correction is insufficient.

Results

Between 1996 and 2005, a total of 161 patients (115 male, 46 female) under the age of 30, including 113 cases of idiopathic scoliosis, were released by simultaneous TARP and posterior surgery. Using the two-portal technique, 131 were mobilized from the right and 30 from the left hand side. Average surgical time spanned 69 min, in which on average 3.2 apical segments were addressed. In 3 individuals, an additional retroperitoneoscopic release was used to liberate a rigid lumbar curve. After 10 years, in a prospectively evaluated subgroup of 32 patients with adolescent idiopathic scoliosis, the index curve had maintained a coronal correction of 70 % (immediately post-surgery 75 %), kyphosis was permanently normalized at 30° (Th5–Th12), and indirect rib hump was reduced to 2.2 cm. In 23 out of 32 patients the lumbar curve corrected spontaneously, obviating the need for fusion. In 13 patients, the lower instrumented vertebra lay at Th12 or higher, thus leaving the thoraco-lumbar junction fairly free. Minor complications (Huang 1or 2) occurred in 4 patients; 1 patient with hematothorax required revision. A distance <25 mm from the spine to the chest wall precludes TARP. Other limitations (e.g., pleural adhesions) were not encountered.

Conclusion

Long-term evaluation after 10–18 years shows that an additional thoracoscopically assisted anterior release at the same time as a posterior standard scoliosis procedure is a justified and effective tool, yielding better results and maintaining them.

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Authors and Affiliations

  1. Abt. für Wirbelsäulenchirurgie, Zentralklinik Bad Berka, Robert-Koch-Allee 9, 99437, Bad Berka, Deutschland

    H. Böhm &  M. Shousha

  2. Abt. Orthopädie, El-Azhar University Hospital, Kairo, Ägypten

    H. El Ghait

  3. Abt. Orthopädie, Alexandria University Hospital, Alexandria, Ägypten

    M. Shousha

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  1. H. Böhm
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  2. H. El Ghait
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  3. M. Shousha
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Correspondence to M. Shousha.

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H. Böhm, H. El Ghait und M. Shousha geben an, dass kein Interessenkonflikt besteht.

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Böhm, H., El Ghait, H. & Shousha, M. Thorakoskopisches ventrales Release in Bauchlage simultan zur dorsalen Korrekturspondylodese. Orthopäde 44, 885–895 (2015). https://doi.org/10.1007/s00132-015-3167-z

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