Auswirkung der dorsalen intersomatischen Spondylodese auf das sagittale lumbale Wirbelsäulenprofil

Zusammenfassung

Studienziel: Ziel dieser Studie war es, den Einfluss von unterschiedlichen Cagegeometrien sowie einer zusätzlichen dorsalen pedikulären Instrumentierung unter besonderer Berücksichtigung des sagittalen lumbalen Wirbelsäulenprofils zu objektivieren. Methode: Diese Studie basiert auf einer retrospektiven Evaluierung von 119 Patienten, bei denen aufgrund einer degenerativen oder diskogenen segmentalen Instabilität eine monosegmentale Spondylodese in PLIF-Technik mit PEEK-Cages durchgeführt wurde. Ergebnisse: Unabhängig der Cagegeometrie zeigte sich postoperativ eine Verbesserung des lumbalen Wirbelsäulenprofils. Zwischen 0°-Standard- und 4°-trapezoiden Implantaten konnte keine signifikante Differenz hinsichtlich der Korrektur der Gesamtlordose, der Zwischenwirbelraumhöhe, des Wirbelgleitens und der sakralen Inklination nachgewiesen werden. Im Segment LWK 4/5 zeigte sich für 4° optimierte Cages eine tendenziell bessere Wiederherstellung der segmentalen Lordose. Die Reliabilität der röntgenologischen Auswertung, gemessen als „intra-observer”-Fehler, war zufrieden stellend. Die klinischen Ergebnisse unterschieden sich zwischen beiden Cagegeometrien nicht. Bei Kombinierung der intersomatischen Spondylodese mit einer dorsalen Instrumentierung (Fixateur interne) war eine bessere Korrektur hinsichtlich des Wirbelgleitens und der Zwischenwirbelraumhöhe festzustellen. Ohne dorsale Instrumentierung zeigten sich eine höhere Pseudarthroserate sowie schlechtere Scorewerte bei der klinischen Auswertung. Schlussfolgerung: Bei monosegmentalen Fusionen kann sowohl mit 0°- als auch 4°-trapezförmigen Implantaten eine Normalisierung des sagittalen Wirbelsäulenprofils erreicht werden. Obwohl für 4° lordosierende Implantate keine eindeutigen Vorteile nachgewiesen wurden, bieten diese zumindest theoretisch eine weitere intraoperative Möglichkeit zur Verbesserung des Wirbelsäulenprofils. Aufgrund der besseren Korrekturmöglichkeit von präoperativen Fehlstellungen sowie einer geringeren Pseudarthrose- und cageassoziierten Komplikationsrate ist die Kombination von intersomatischen Cages mit einer zusätzlichen dorsalen Instrumentierung zu empfehlen.

Abstract

Aim: To determine the effect of different cage geometries and posterior instrumentation on the sagittal spinal profile after monosegmental lumbar interbody fusion. Method: The study is based on a retrospective analysis of 119 patients with segmental instability, who were surgically managed by monosegmental PLIF with PEEK-Cages and dorsal instrumentation. Results: At radiographic follow-up after surgery we found a significant improvement of the lumbar sagittal spinal profile, independent of the cage geometry utilised. A marked discrepancy between 0°-standard and 4°-trapezoid implants concerning the radiographic parameters lumbar lordosis, disc height, correction of spondylolisthesis and sacral inclination was not found. With the use of 4° optimised cages in segment L4/5 slightly better results for segmental lordosis were obtained. Reliability of the radiographic evaluation, expressed as intra-observer error, was satisfactory. Cage geometry did not have an effect on the clinical result. By combining interbody fusion with pedicular instrumentation the reposition of slipped vertebra and distraction of the interbody space could more effectively be achieved. Patients without dorsal instrumentation had a higher rate of pseudarthrosis as well as a less satisfactory clinical outcome. Conclusion: These results show that normal sagittal alignment after single-level lumbar fusion can be achieved with rectangular and 4°-wedged cages. Although results after utilization of 4°-wedged cages do not significantly differ, these implants offer the surgeon one more sizing variation with which physiological lumbar lordosis may be attained. The combination of intersomatic implants with dorsal instrumentation achieves a more precise realignment and has a lower rate of cage-associated complications. It therefore seems prudent that an interbody fusion for the surgical management of lumbar segmental instability should be combined with pedicular instrumentation.

Schlüsselwörter

Wirbelsäulenprofil - Cage - Lordose - Fixateur - PLIF

Key words

Spinal profile - interbody cage - pedicular instrumentation - PLIF - lordosis

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