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Thorakale und lumbale Wirbelsäule

Wie viel ventral geht von dorsal?

Thoracic and lumbar spine

Anterior stabilization via posterior approach?

  • Leitthema
  • Published:
Trauma und Berufskrankheit

Zusammenfassung

Trotz jahrzehntelanger Erfahrung und einer Fülle an Studien herrscht bis heute keine Einigkeit bezüglich der optimalen Versorgung und des Zugangsweges bei Instabilitäten der Brust und Lendenwirbelsäule. Neben der dorsalen Zuggurtung ist die ventrale Abstützung ein Grundpfeiler der Versorgung in diesem Bereich. Die kombinierte Stabilisierung von ventral und dorsal bietet neben einer exzellenten Übersicht das stabilste biomechanische Konstrukt. Bei einer Versorgung über zwei separate Zugänge werden die Morbidität des Patienten und die möglichen Komplikationen jedoch addiert. Eine ventrale Versorgung über einen dorsalen Zugangsweg scheint daher hinsichtlich der Komplikationen, des Blutverlusts und der Operationsdauer von Vorteil zu sein. Über einen modifizierten Posterior-lumbar-interbody-fusion(PLIF)-/Transforaminal-lumbar-interbody-fusion(TLIF)-Zugang können auf diese Weise ventrale Defekte aufgefüllt werden. Insbesondere im Bereich der Lendenwirbelsäule ist dies jedoch durch die abgehenden Nervenwurzeln anatomisch beschränkt. Häufig sind nur eine Teilkorporektomie und die Auffüllung des verletzten Bandscheibenraumes erforderlich. Durch aufspreizbare Cages gelingt jedoch auch der Ersatz ganzer Wirbelkörper. Patientenfaktoren und der Operateur beeinflussen weiterhin die gewählte Operationstechnik.

Abstract

Despite more than 50 years of experience and extensive research regarding instabilities of the thoracic and lumbar spine, no consensus exists about preferable techniques and approaches. Posterior instrumentation and anterior vertebral height restoration are the keystones of spinal instability treatment. The combination of anterior transcavitary and posterior approaches provides excellent visualization and biomechanical stability. Utilizing a double approach may lead to “double approach morbidity” and possible complications may sum up. Anterior column reconstruction via a single-stage posterior approach seems to be advantageous regarding complication, blood loss, and operating room time. Vertebral body and intervertebral disc defects can be replaced utilizing a modified posterior lumbar interbody fusion (PLIF)/transforaminal lumbar interbody fusion (TLIF) approach. In the lumbar region, nerve roots anatomically limit the operative field and the space for anterior instrumentation. Partial corpectomy and intervertebral disc removal followed by cage and/or bone graft replacement is often sufficient for anterior stabilization and bony fusion. Transpedicular vertebrectomy and circumferential reconstruction became feasible due to expandable cages. Patient-related factors and surgeon’s preferences continue to influence surgical decision-making and treatment.

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Authors and Affiliations

  1. Chirurgische Universitätsklinik und Poliklinik, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland

    M. F. Hoffmann

  2. Abteilung für Unfall- und Wiederherstellungschirurgie, Asklepios Klinik St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Deutschland

    J. Madert

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Correspondence to M. F. Hoffmann.

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M. F. Hoffmann und J. Madert geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Hoffmann, M.F., Madert, J. Thorakale und lumbale Wirbelsäule. Trauma Berufskrankh 19, 74–79 (2017). https://doi.org/10.1007/s10039-017-0258-6

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  • DOI: https://doi.org/10.1007/s10039-017-0258-6

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