Zusammenfassung
Hintergrund: Die Datenlage bezüglich der Morbidität sowie der
mittelfristigen Ergebnisse nach ventraler thorakoskopischer Spondylodese
(VTS) beim älteren Patienten ist limitiert. Methodik: 23 Patienten
mit traumatischer Wirbelkörperfraktur des thorakolumbalen Übergangs wurden
eingeschlossen. Ein Alter über 60 Jahre und die VTS-Versorgung waren
Voraussetzungen. Das Durchschnittsalter betrug 65 Jahre. In 87 % der Fälle
lag eine A-Verletzung vor. In 21 Fällen erfolgte ein dorsoventrales Vorgehen
mit bisegmentaler Spondylodese. Durchschnittlich 3,9 Jahre postoperativ
erfolgten radiologische Verlaufskontrollen sowie die Evaluation mit SF-36-
(Short Form 36) und ODI- (Oswestry Disability Index) Scores.
Ergebnisse: Bei 5 Patienten kam es zu pulmonalen Komplikationen.
Der durchschnittliche Korrekturverlust betrug 3,2°. Bei 4 Patienten kam es
intraoperativ zu einer Grund- bzw. Deckplattenläsion mit einhergehendem
signifikant höherem Korrekturverlust (13,6° ± 4,5°; p < 0,001). Die
Score-Ergebnisse von SF 36 und ODI zeigten keine signifikanten Unterschiede
zum statistischen Vergleichskollektiv und nur geringe
wirbelsäulenspezifische Einschränkungen. Schlussfolgerung: Die VTS
scheint auch beim älteren Patienten eine sinnvolle Behandlungsstrategie
darzustellen. Die exakte Präparation Grund-/Deckplatte scheint bez. der
dauerhaften Herstellung des sagittalen Profils maßgeblich zu sein.
Abstract
Background: Only limited data are available concerning the effect of
ventral thoracoscopic spondylodesis (VTS) on elderly patients and the
medium-term outcome. Material and Method: In a retrospective study,
23 patients were included from 2003 to 2008. An age over 60, a traumatic
burst fracture in the thoracolumbar region and a VTS procedure were
inclusion criteria. A preoperative neurological deficit, ASA scores greater
than 3 and a malignant disease were exclusion criteria. The mean age was 65
(62–70) years, 17 male and 6 female patients were included. In 87 % (n = 18)
of the patients a compression fracture type A was found. Bone density values
were obtained in 5 patients, mean value was −1,7. 21 patients were treated
with a dorsoventral, bisegmental procedure. Two patients with limited
kyphosis and no relevant stenosis of the spinal canal were treated with a
ventral only procedure. In two cases with measured low bone quality, pedicle
screws were placed with bone cement. Patients were monitored on ICU for 24
hours after operation until the thoracic drainage was removed. At an average
follow-up of 3.9 years, patients were evaluated with SF 36 (short form 36)
and an Oswestry disability index score (ODI score). The postoperative
radiographic control was performed with a CT scan, X-ray controls were taken
3, 6, 12 and 18 months after the operation. Cobb angle and scoliosis angle
were measured. Statistical analysis was carried out with SPSS-Software 17.0
(SPSS®, Inc., Chicago, USA) and a Mann-Whitney U test and a level of
significance of p < 0,05. Results: In five patients pulmonary
complications occurred, in one case a revision operation had to be performed
due to pleural effusion. One patient suffered from a delayed pneumonia. The
mean loss of correction in all patients was 3,3° (−20°–1°). In four patients
with a distinct loss of correction at an average of 13,6° ± 4,5°, iatrogenic
damage of the lower or upper cover plate of the adjacent vertebral bodies
was found. The risk of loss of correction was found to be significantly
higher in case of damage to the lower or upper cover plate (p < 0.001).
Test results from the SF 36 score (sum scale 40.8) showed no significant
difference in life quality to a similar aged comparison group. The ODI score
revealed a mean vertebral column associated impairment of 10.8 %, 20
patients showed only minimal limitations. Conclusion: Also in older
patients VTS seems to be an adequate treatment of traumatic burst fractures
of the thoracolumbar spine. Perioperative pulmonary complications were easy
to handle and had no effect on the clinical outcome. Postoperative
radiographs showed only little loss of correction, in four cases iatrogenic
damage of the cover-plate led to a distinct loss of correction. Careful and
accurate preparation of the cover plates is therefore decisive.
Schlüsselwörter
ventrale thorakoskopische Spondylodese - thorakolumbaler Übergang - ältere Patienten
- traumatische Wirbelkörperfraktur
Key words
thoracoscopic ventral spondylodesis - thoracolumbar spine - elderly patients - traumatic
burst fractures
