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Evaluation des sagittalen Profils nach operativer Therapie der thorakalen adoleszenten idiopathischen Skoliose Lenke Typ 1

Evaluation of the sagittal profile in patients with thoracic adolescent idiopathic scoliosis Lenke type 1 following posterior correction

Der Orthopäde volume 42, pages 150–156 (2013)Cite this article

Zusammenfassung

Hintergrund

Die Behandlungsstrategie der adoleszenten idiopathischen Skoliose (AIS) mittels dorsaler Korrekturspondylodese hat sich in den letzten Jahrzehnten verändert. Primär lag der Fokus auf der Korrektur der Hauptkurve in der Frontalebene, ohne das sagittale Profil bei der Operationsplanung zu berücksichtigen. In verschiedenen Langzeitstudien wurde nachgewiesen, dass nach Skolioseoperationen viele Patienten unter einem Flachrücken („flatback syndrome“) mit Rückenschmerzen litten. Es wurde daher postuliert, dass die optimale chirurgische Versorgung der thorakalen adoleszenten idiopathischen Skoliose auch die Erhaltung der sagittalen Balance und der lumbalen Lordose berücksichtigen sollte. Allerdings existieren nur wenige Studien, welche den Effekt zusätzlicher Prozeduren zum Erhalt des sagittalen Profils untersuchten.

Material und Methoden

Ziel der vorliegenden Studie ist es, den Effekt verschiedener dorsaler Operationstechniken auf das sagittale Profil zu untersuchen. Retrospektiv wurden 36 Patienten mit thorakaler idiopathischen Adoleszentenskoliose eingeschlossen, welche mittels dorsaler Korrekturspondylodese versorgt wurden. Unter Berücksichtigung verschiedener Korrekturprinzipien wurden die Patienten in Subgruppen eingeteilt (A Pedikelschraube, B Langkopfpedikelschraube, C Langkopfpedikelschraube mit Ponte-Osteotomien). Standardröntgenaufnahmen der ganzen Wirbelsäule im Stehen wurden vor und mindestens 2 Jahre nach dorsaler Korrektur angefertigt. Eine Subgruppenanalyse wurde zur Detektierung von Gruppenunterschieden vorgenommen.

Ergebnisse

In allen 3 Gruppen wurde eine signifikante Korrektur der Hauptkurve nachgewiesen (p < 0,001). Das Korrekturausmaß der Hauptkurve war in den Gruppen B und C signifikant höher als in Gruppe A (p < 0,001). Bezüglich des sagittalen Profils wurden signifikante Unterschiede zwischen den Gruppen gefunden. Während sich eine signifikante Verminderung der Thorakalkyphose (TK) sowie der Lendenlordose (LL) in den Gruppen A und B zeigte, kam es in Gruppe C zur signifikanten Erhöhung beider Parameter (p < 0,001). Diese Veränderungen in Gruppe C waren mit einer signifikanten Verminderung des „pelvic tilt“ sowie einer signifikanten Erhöhung des „sacral slope“ assoziiert. Nur in Gruppe C war in der 2-Jahres-Nachuntersuchung der ODI-%-Wert am niedrigsten und mit der Reduktion des „pelvic tilt“ positiv korreliert.

Schlussfolgerung

Die Ergebnisse unserer Studie unterstreichen, das eine isolierte dorsale Korrekturspondylodese ohne Berücksichtigung des sagittalen Profils zwar zur signifikanten Reduktion der Hauptkurve in der Frontalebene führt, jedoch regelhaft zur Verschlechterung des sagittalen Profils („Flachrückensyndrom“) beitragen kann. Weiter wurde nachgewiesen, dass zusätzliche Techniken, welche das sagittale Profil beeinflussen, zur signifikanten Verbesserung der TK sowie der LL führen. Sie sind daher für die Korrektur der thorakalen idiopathischen Adoleszentenskoliose Typ Lenke 1 zu empfehlen.

Abstract

Introduction

The principle philosophy of posterior spinal instrumentation and fusion (PSIF) for the treatment of adolescent idiopathic scoliosis (AIS) has changed during recent decades. In the past the treatment of AIS mainly focused on correction of the major curve in the frontal plane while the sagittal profile and balancing were only of inferior interest in treatment planning. Various long-term outcome studies have demonstrated that many AIS patients developed a flatback syndrome (decrease of thoracic kyphosis and lumbar lordosis) associated with pain. It was concluded that treatment of AIS should consider the sagittal profile and balance; however, there are only few studies addressing additional procedures, which include the correction of the sagittal profile.

Material and methods

The purpose of this study was to evaluate the effects of different posterior correction techniques on sagittal profile and balance. A total of 36 consecutive patients with thoracic AIS, who were treated with selective thoracic posterior correction were included in this retrospective study. The patients were further assigned to three different subgroups according to different surgical strategies: A: pedicle screws, B: long-head pedicle screws and C: additional Ponte osteotomy. Standardized radiographs in the standing position of the whole spine in two planes were evaluated before and at least 2 years after correction for all patients and a subgroup analysis was done to identify differences between the three groups.

Results

A significant correction of the major curve was achieved in all three groups (p < 0.001). There was a significant difference between the groups with groups B and C showing significantly higher levels of major curve correction in comparison to group A (p < 0.001). Concerning the sagittal profile, there was a significant difference in the development of thoracic kyphosis (TK) and lumbar lordosis (LL). While a significant reduction of TK and LL was found in groups A and B after surgery, a significant increase of TK and LL was noted in group C which was associated with a decrease of pelvic tilt and an increase of sacral slope. The 2-year follow-up showed the lowest ODI-% value only in group C which was positively correlated with reduction in pelvic tilt.

Conclusions

The results of this study underline that the PSIF technique alone using pedicle screws leads to a satisfactory correction in the frontal plane but is associated with adverse effects on the sagittal profile (flat back syndrome), corroborating previous studies. It was further shown that significant improvements of sagittal parameters were achieved by adding techniques for the lengthening of the dorsal thoracic column. This approach can therefore be recommended for the treatment of AIS Lenke type 1.

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Affiliations

  1. Department Orthopädie, Unfallchirurgie und Paraplegiologie, Zentrum für Wirbelsäulenchirurgie, Stiftung Orthopädische Universitätsklinik Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland

    M. Akbar, T. Dreher, G. Omlor, H. Wang, C. Carstens &  B. Wiedenhöfer

  2. Spine Deformity Service, Division of Spine Surgery, Hospital for Joint Diseases, New York University School of Medicine, New York, USA

    F. Schwab

  3. Institut für Medizinische Biometrie und Informatik, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland

    T. Bruckner

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  1. M. Akbar
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  2. T. Dreher
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  3. F. Schwab
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  4. G. Omlor
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Correspondence to M. Akbar or B. Wiedenhöfer.

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Akbar, M., Dreher, T., Schwab, F. et al. Evaluation des sagittalen Profils nach operativer Therapie der thorakalen adoleszenten idiopathischen Skoliose Lenke Typ 1. Orthopäde 42, 150–156 (2013). https://doi.org/10.1007/s00132-012-2060-2

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Schlüsselwörter

  • Thorakale Kyphose
  • Lumbale Lordose
  • „Pelvic tilt“
  • „Sacral slope“
  • Spinopelvine Parameter

Keywords

  • Thoracic kyphosis
  • Lumbar lordosis
  • Pelvic tilt
  • Sacral slope
  • Spinopelvic parameters