Verletzungen der thorakolumbalen Wirbelsäule: Konservative und operative Therapie

Zusammenfassung

Verletzungen der Brust- und Lendenwirbelsäule des knochengesunden Patienten entstehen meist durch große Gewalteinwirkung. Höhe und Vektor der einwirkenden Energie beeinflussen hierbei maßgeblich das Verletzungsmuster der Wirbelsäule, welches von der einfachen Kompressionsfraktur bis hin zur Luxationsfraktur mit neurologischen Defiziten reichen kann. Die Schwere der Verletzung und patientenindividuelle Faktoren bestimmen das therapeutische Prozedere. Während einfache Verletzungen ohne Fehlstellungen eine Domäne der konservativen Therapie sind, erfordern komplexe Luxationsfrakturen häufig eine mehrzeitige Stabilisierung und Rekonstruktion der vorderen und hinteren Säule. Anspruchsvoll kann jedoch auch das Erkennen nicht offensichtlicher Instabilitäten bei intermediären Verletzungsmustern sein, deren korrekte Therapie sich häufig erst nach erweiterter Bildgebung und sorgfältiger Befundinterpretation festlegen lässt.

Unzureichende Diagnostik und Missinterpretation von Befunden führen zu Fehlbehandlungen, welche in chronischen Instabilitäten und Fehlstellungen münden können. Der folgende Artikel hat das Ziel, einen aktuellen Überblick über die verschiedenen Behandlungsaspekte der verletzten Brust- und Lendenwirbelsäule zu geben.

Abstract

Injuries of the thoracic and lumbar spine in patients who are not suffering from bone disease are usually the result of high energy trauma. The amount of energy and the vector of the impact significantly determine the injury pattern, which can reach from simple vertebral body compression to severe fracture dislocation with neurologic impairment. The magnitude of the injury as well as individual patient characteristics have an influence on the further treatment. Simple fractures with non or minor dislocation are a domain of conservative treatment, while complex injury patterns often require a two-staged stabilization and reconstruction of the anterior and posterior column of the spine. Likewise, the assessment of intermediate injuries with unapparent instability can be demanding. In these cases, determining the appropriate therapy may take further imaging and accurate evaluation of the results.

Insufficient diagnostics and wrong interpretation of findings lead to inadequate therapy which can result in chronic instability or false posture. This article has the agenda to outline the current state of diagnostics and therapy of the injured thoracic and lumbar spine.

Schlüsselwörter

Brustwirbelsäule - Lendenwirbelsäule - Fraktur - konservativ - operativ

Keywords

thoracic spine - lumbar spine - fracture - non-operative - operative

Publication History

Article published online:
16 April 2024

• Literatur

• 1 Reinhold M, Knop C, Beisse R. et al. Operative treatment of 733 patients with acute thoracolumbar spinal injuries: comprehensive results from the second, prospective, internet-based multicenter study of the Spine Study Group of the German Association of Trauma Surgery. Eur Spine J 2010; 19: 1657-1676 DOI: 10.1007/s00586-010-1451-5.
• 2 Magerl F, Aebi M, Gertzbein SD. et al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3: 184-201 DOI: 10.1007/BF02221591. (PMID: 7866834)
• 3 Kepler CK, Vaccaro AR, Koerner JD. et al. Reliability analysis of the AOSpine thoracolumbar spine injury classification system by a worldwide group of naïve spinal surgeons. Eur Spine J 2016; 25: 1082-1086 DOI: 10.1007/s00586-015-3765-9. (PMID: 25599849)
• 4 Vaccaro AR, Oner C, Kepler CK. et al. AOSpine Thoracolumbar Spine Injury Classification System: Fracture Description, Neurological Status, and Key Modifiers. Spine 2013; 38: 2028-2037 DOI: 10.1097/BRS.0b013e3182a8a381. (PMID: 23970107)
• 5 Kandziora F, Schleicher P, Reinhold M. et al. Die AOSpine-Klassifikation thorakolumbaler Verletzungen. Orthop Unfallchirurgie Up2date 2016; 11: 407-423 DOI: 10.1055/s-0042-103119.
• 6 Vaccaro AR, Lehman RA, Hurlbert RJ. et al. A New Classification of Thoracolumbar Injuries: The Importance of Injury Morphology, the Integrity of the Posterior Ligamentous Complex, and Neurologic Status. Spine 2005; 30: 2325-2333 DOI: 10.1097/01.brs.0000182986.43345.cb. (PMID: 16227897)
• 7 Bloess K, Stein GM, Faymonville C. Abweichung des individuellen physiologischen Profils der Wirbelsäule. In: Stein GM, Eysel P, Scheyerer MJ. Expertise Orthopädie und Unfallchirurgie Wirbelsäule. Georg Thieme Verlag; 2019: 148-149
• 8 Bernhardt M, Bridwell KH. Segmental Analysis of the Sagittal Plane Alignment of the Normal Thoracic and Lumbar Spines and Thoracolumbar Junction. Spine 1989; 14: 717-721 DOI: 10.1097/00007632-198907000-00012. (PMID: 2772721)
• 9 Scheyerer MJ, Ullrich B, Osterhoff G. et al. „Hounsfield units“ als Maß für die Knochendichte – Anwendungsmöglichkeiten in der Wirbelsäulenchirurgie. Unfallchirurg 2019; 122: 654-661 DOI: 10.1007/s00113-019-0658-0.
• 10 McCormack T, Karaikovic E, Gaines RW. The Load Sharing Classification of Spine Fractures. Spine 1994; 19: 1741-1744 DOI: 10.1097/00007632-199408000-00014. (PMID: 7973969)
• 11 De Iure F, Lofrese G, De Bonis P. et al. Vertebral body spread in thoracolumbar burst fractures can predict posterior construct failure. Spine J 2018; 18: 1005-1013 DOI: 10.1016/j.spinee.2017.10.064. (PMID: 29074467)
• 12 Sander AL, Lehnert T, Saman AE. et al. Outcome of Traumatic Intervertebral Disk Lesions After Stabilization by Internal Fixator. Am J Roentgenol 2014; 203: 140-145 DOI: 10.2214/AJR.13.11590. (PMID: 24951207)
• 13 Vaccaro AR, Schroeder GD, Kepler CK. et al. The surgical algorithm for the AOSpine thoracolumbar spine injury classification system. Eur Spine J 2016; 25: 1087-1094 DOI: 10.1007/s00586-015-3982-2. (PMID: 25953527)
• 14 Kepler CK, Vaccaro AR, Schroeder GD. et al. The Thoracolumbar AOSpine Injury Score. Glob Spine J 2016; 6: 329-334 DOI: 10.1055/s-0035-1563610. (PMID: 27190734)
• 15 Peev N, Zileli M, Sharif S. et al. Indications for Nonsurgical Treatment of Thoracolumbar Spine Fractures: WFNS Spine Committee Recommendations. Neurospine 2021; 18: 713-724 DOI: 10.14245/ns.2142390.195. (PMID: 35000324)
• 16 Yildiz U, Schleicher P, Castein J. et al. Konservative Behandlung von Wirbelfrakturen in BWS und LWS – was geht wie?. Wirbels 2019; 03: 313-335 DOI: 10.1055/a-0980-9182.
• 17 Bailey CS, Urquhart JC, Dvorak MF. et al. Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial. Spine J 2014; 14: 2557-2564 DOI: 10.1016/j.spinee.2013.10.017.
• 18 Tan T, Huang MS, Rutges J. et al. Rate and Predictors of Failure in the Conservative Management of Stable Thoracolumbar Burst Fractures: A Systematic Review and Meta-Analysis. Glob Spine J 2022; 12: 1254-1266 DOI: 10.1177/21925682211031207. (PMID: 34275348)
• 19 Verlaan JJ, Diekerhof CH, Buskens E. et al. Surgical Treatment of Traumatic Fractures of the Thoracic and Lumbar Spine: A Systematic Review of the Literature on Techniques, Complications, and Outcome. Spine 2004; 29: 803-814 DOI: 10.1097/01.BRS.0000116990.31984.A9. (PMID: 15087804)
• 20 Spine secrets. Third edition. Devlin VJ. Philadelphia, PA: Elsevier; 2021
• 21 Knop C, Blauth M, Bastian L. et al. Fractures of the thoracolumbar spine. Unfallchirurg 1997; 100: 630-639 DOI: 10.1007/s001130050168. (PMID: 9381211)
• 22 Lakshmanan P, Jones A, Mehta J. et al. Recurrence of kyphosis and its functional implications after surgical stabilization of dorsolumbar unstable burst fractures. Spine J 2009; 9: 1003-1009 DOI: 10.1016/j.spinee.2009.08.457. (PMID: 19819190)
• 23 Wang X-Y, Dai L-Y, Xu H-Z. et al. Kyphosis recurrence after posterior short-segment fixation in thoracolumbar burst fractures. J Neurosurg Spine 2008; 8: 246-254 DOI: 10.3171/SPI/2008/8/3/246. (PMID: 18312076)
• 24 Kandziora F, Schnake KJ, Pingel A. et al. Posttraumatische thorakolumbale Kyphose. Trauma Berufskrankh 2009; 11: 80-86 DOI: 10.1007/s10039-009-1487-0.
• 25 P. Oprel P, Tuinebreijer WE, Patka P. et al. Combined Anterior-Posterior Surgery Versus Posterior Surgery for Thoracolumbar Burst Fractures: A Systematic Review of the Literature. Open Orthop J 2010; 4: 93-100 DOI: 10.2174/1874325001004010093.
• 26 Scholz M, Kandziora F, Tschauder T. et al. Prospective randomized controlled comparison of posterior vs. posterior–anterior stabilization of thoracolumbar incomplete cranial burst fractures in neurological intact patients: the RASPUTHINE pilot study. Eur Spine J 2018; 27: 3016-3024 DOI: 10.1007/s00586-017-5356-4. (PMID: 29071409)
• 27 Schnake KJ, Stavridis SI, Kandziora F. Five-year clinical and radiological results of combined anteroposterior stabilization of thoracolumbar fractures: Clinical article. J Neurosurg Spine 2014; 20: 497-504 DOI: 10.3171/2014.1.SPINE13246. (PMID: 24606000)
• 28 Glassman SD, Bridwell K, Dimar JR. et al. The Impact of Positive Sagittal Balance in Adult Spinal Deformity. Spine 2005; 30: 2024-2029 DOI: 10.1097/01.brs.0000179086.30449.96.
• 29 Le Huec JC, Thompson W, Mohsinaly Y. et al. Sagittal balance of the spine. Eur Spine J 2019; 28: 1889-1905 DOI: 10.1007/s00586-019-06083-1. (PMID: 31332569)
• 30 McLain RF. Functional Outcomes After Surgery for Spinal Fractures: Return to Work and Activity: Spine 2004; 29: 470–477. . DOI: 10.1097/01.BRS.0000092373.57039.FC. (PMID: 15094545)
• 31 Soultanis K, Thano A, Soucacos PN. “Outcome of thoracolumbar compression fractures following non-operative treatment”. Injury 2021; 52: 3685-3690 DOI: 10.1016/j.injury.2021.05.019. (PMID: 34049701)
• 32 Rometsch E, Spruit M, Härtl R. et al. Does Operative or Nonoperative Treatment Achieve Better Results in A3 and A4 Spinal Fractures Without Neurological Deficit?: Systematic Literature Review With Meta-Analysis. Glob Spine J 2017; 7: 350-372 DOI: 10.1177/2192568217699202.
• 33 Costa F, Sharif S, Bajamal AH. et al. Clinical and Radiological Factors Affecting Thoracolumbar Fractures Outcome: WFNS Spine Committee Recommendations. Neurospine 2021; 18: 693-703 DOI: 10.14245/ns.2142518.259. (PMID: 35000322)