Zervikale Radikulopathie^[*]

Zusammenfassung

Hintergrund Die zervikale Radikulopathie (ZR) ist ein relativ häufiges Krankheitsbild, welches in sehr vielen Bereichen der Medizin vorkommt und einen interdisziplinären Behandlungsansatz erfordert. Obwohl das Leitsymptom der Schmerz ist, weist die ZR einige Besonderheiten auf, denen die Deutsche Gesellschaft für Neurologie in einer eigenen Leitlinie Rechnung trägt. Das wesentliche Ziel dieser Leitlinie war es, den aktuellen Wissensstand zur Therapie der ZR zu vermitteln. Die vorliegende Leitlinie bezieht sich ausschließlich auf die degenerativ bedingten ZR.

Methodik Der Leitlinie liegt eine Recherche von Leitliniendatenbanken und Medline zugrunde. Unter der Moderation durch die Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) erfolgte die Konsensfindung mittels eines nominalen Gruppenprozesses und des Delphi-Verfahrens. Aufgrund des interdisziplinären Behandlungsansatzes wurde das Leitliniengremium aus Experten verschiedener ärztlicher (Neurologie, Orthopädie, Unfallchirurgie, Neurochirurgie, Schmerztherapie, Physikalische und Rehabilitative Medizin und Manuelle Medizin) und therapeutischer Fachdisziplinen (Ergotherapie, Physiotherapie) und unter Beteiligung der Schmerz-Selbsthilfe (Deutsche Schmerzliga) gebildet.

Ergebnisse Hinsichtlich der Evidenzbewertung der Literatur ist festzustellen, dass die Datenlage zur Frage des optimalen Vorgehens bei ZR sehr heterogen ist. Die Anwendung von Physiotherapie in Kombination von manueller Therapie und Bewegungsübungen sowie bestimmte operative Verfahren bei ZR sind dagegen evidenzbasiert. Starker Konsens besteht bei den beteiligten Fachgesellschaften, dass das primäre Vorgehen in aller Regel konservativ ist. Hier werden Physiotherapie in Kombination von manueller Therapie, Ergotherapie zur Stärkung der Alltagskompetenz, frühzeitige Schmerztherapie, kurzzeitige intermittierende Ruhigstellung durch das Tragen einer Halskrause und eine periradikuläre Infiltrationstherapie empfohlen.

Eine Operation sollte bei therapierefraktärem Schmerzsyndrom nach Ausschöpfung der konservativen Maßnahmen spätestens 6 Monate nach Symptombeginn dem Patienten empfohlen werden. Bei lateralen und intraforaminalen Bandscheibenvorfällen können als Operationsverfahren eine ACDF („anterior cervical discectomy with fusion“) oder eine PCF („posterior cervical foraminotomy“) durchgeführt werden. Das bevorzugte Verfahren ist hier im Einzelfall zu wählen. Bei medianen und paramedianen Bandscheibenvorfällen soll der ventrale Zugang gewählt werden.

Schlussfolgerung Die Diagnose einer ZR beruht auf der Anamnese und der neurologischen Untersuchung und soll durch eine bildgebende Methode bestätigt werden. Bei Fehlen behindernder Ausfälle soll das Vorgehen primär konservativ und bei rasch progredienten Paresen primär operativ sein. Bei Einhalten der in der Leitlinie aufgeführten Empfehlungen haben die Schmerzen bei ZR eine günstige Prognose.

Abstract

Background Cervical Radiculopathy (CR) is a relatively common clinical syndrome that occurs in many areas of medicine and requires an interdisciplinary treatment approach. Although the main symptom is pain, the CR has some particularities, which the German Neurological Society takes into account in its own guideline. The main aim of this guideline was to convey the current state of knowledge for the treatment of CR. This guideline refers exclusively to the degenerative CR.

Methodology The guideline is based on a search of guideline databases and medline. Under the moderation of the German Association of Scientific Medical Societies (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF)), the consensus was reached by means of a nominal group process and the Delphi process. Due to the interdisciplinary treatment approach, the guideline committee was formed from experts of various medical (neurology, orthopedics, trauma surgery, neurosurgery, pain therapy, physical and rehabilitative medicine and manual medicine) and therapeutic disciplines (occupational therapy, physiotherapy) and the participation of pain self-help (German pain league).

Results With regard to the evidence evaluation of the literature, it can be stated that the data on the question of the optimal procedure in CR is very heterogeneous. The use of physiotherapy in combination with manual therapy and movement exercises as well as certain surgical procedures in CR are evidence-based. There is a strong consensus among the participating medical societies that the primary approach is usually conservative. Physiotherapy in combination with manual therapy, occupational therapy to strengthen everyday life skills, early pain therapy, short-term intermittent immobilization by wearing a neck brace and periradicular infiltration therapy are recommended.

Surgery should be recommended to the patient in the case of treatment-refractory pain syndrome after the use of conservative measures no later than 6 months after onset of symptoms. For lateral and intraforaminal disc herniations, an ACDF ("anterior cervical discectomy with fusion") or a PCF ("posterior cervical foraminotomy") may be used as the surgical procedure. The preferred method should be chosen here on an individual basis. For median and paramedian disc herniations, the ventral approach should be chosen.

Conclusion The diagnosis of a CR is based on the anamnesis and the neurological examination and should be confirmed by an imaging method. In the absence of obstructive failures, the procedure should be primarily conservative and only primarily operative in rapidly progressive paresis. If the recommendations in the guideline are adhered to, the pain in ZR has a favorable prognosis.

^* Den Leitlinientext zusammen mit der Interessenkonflikterklärung finden Sie auch auf www.dgn.org sowie www.awmf.de.

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