Operative und konservative Behandlung von Wirbelfrakturen im Alter

Zusammenfassung

Die demografische Entwicklung in Deutschland führt zu einer Überalterung der Bevölkerung. Gerade bei diesen Patienten stellen die osteoporosebedingten Wirbelfrakturen einen deutlichen Einschnitt in das Leben und das Aktivitätsniveau dar. Nach aktueller Leitlinie stellt zunächst die konservative Behandlung der stabilen osteoporotischen Wirbelfraktur, bestehend aus analgetischen, antiosteoporotischen, physiotherapeutischen und orthetischen Maßnahmen die Therapie der ersten Wahl dar, aus eigener Erfahrung hingegen profitieren die Patienten von einer zeitnahen operativen Behandlung durch eine schnelle Verbesserung der Schmerzsituation und damit schnelleren Mobilisierung. Die schlechte Knochenqualität der betagten Patienten stellt den behandelnden Wirbelsäulenchirurgen vor die große Aufgabe, eine entsprechend stabile Spondylodese zu erzielen oder diese z. B. durch Augmentation weiter zu unterstützen. Hier haben sich in den letzten Jahren in zunehmenden Maße minimalinvasive Verfahren etablieren können. In Abhängigkeit vom Alter des Patienten und von der Frakturmorphologie haben wir bei über 1000 Frakturversorgungen in den letzten 3,5 Jahren ein differenziertes Behandlungskonzept entwickelt, das wir vorstellen möchten. Instabile Frakturen mit Beteiligung der Hinterkante werden dabei von dorsal mit einem Fixateur perkutan stabilisiert. Patienten über 60 Jahre werden perkutan mit einem polyaxialen Schraubensystem behandelt. Zur Erhöhung der Stabilität werden die fenestrierten Schrauben mit PMMA-Zement augmentiert. Beim älteren Patienten mit Magerl-A3-Frakturen ohne neurologisches Defizit wird der Indexwirbel ergänzend kyphoplastiert (Hybridversorgung). Bei frischen stabilen osteoporotischen Wirbelfrakturen mit starken Schmerzen trotz Analgetika führen wir eine Kyphoplastie durch, die mit kleineren Ballons und dünneren Arbeitstrokaren auch bei hoch thorakalen Frakturen bis Th III möglich ist. Eine Vertebroplastie stellt im LWS- und unteren BWS-Bereich ebenfalls eine Option dar. Ausgedehnte dorsoventrale Korrektureingriffe sind bei der häufig multimorbiden Patientengruppe aufgrund der Invasivität eher Ausnahmefällen vorbehalten.

Schlüsselwörter

Osteoporose - Wirbelsäulenchirurgie - Wirbelfraktur - Zementaugmentation - perkutane Stabilisierung

• References/Literatur

• 1 Pingel A, Kandziora F, Hoffmann CH. Osteoporotic L1 burst fracture treated by short-segment percutaneous stabilization with cement-augmented screws and kyphoplasty (hybrid technique). Eur Spine J 2014; 23: 2022-2023
• 2 Prokop A, Reinauer KM, Futterer N. et al. Lohnt sich eine Zertifizierung in der Unfallchirurgie? Erfahrungen aus einem zertifizierten Zentrum für Alterstraumatologie. DGU Mitteilungen und Nachrichten 2010; 62: 18-19
• 3 Prokop A, Löhlein F, Chmielnicki M. et al. Minimally invasive dorsale instrumentation with spine fractures. More expensive or even better?. Eur Spine J 2008; 17: 1612-1613
• 4 Kraus M, Schultheiß M, Gebhard F. Wirbelsäulenverletzungen und Unfallfolgezustände. Trauma Berufskrankh 2010; 12: 78-87
• 5 Prokop A, Löhlein F, Chmielnicki M. et al. [Minimally invasive percutaneous instrumentation for spine fractures]. Unfallchirurg 2009; 112: 621-624 626–628
• 6 Prokop A, Stenz R, Löhlein F. et al. Vesselplasty – new method in treatment of osteoporotic spine fractures. Langenbecks Arch Surg 2009; 394: 965
• 7 Prokop A, Wollny M, Futterer N. et al. [Operative treatment of instable osteoporotic spine fractures. A good guide in coding of diagnosis]. Unfallchirurg 2009; 112: 815-819
• 8 Prokop A, Chmielnicki M, Greiling M. Analysis of costs in kyphoplasty. Eur Spine J 2010; 19: 2060
• 9 Prokop A, Chmielnicki M, Volbracht J. DRG 2010 bei Wirbelfrakturen. Orthopädische Nachrichten 2010; 10: 17-18
• 10 Prokop A, Löhlein F, Chmielnicki M. et al. [Kyphoplasty in osteoporotic spinal fractures]. Unfallchirurg 2010; 113: 127-132
• 11 Prokop A, Berner U, Muszynski T. et al. Prozesskostenanalyse von Kyphoplastien bei osteoporotischen Sinterungsfrakturen. Unfallchirurg 2011; 114: 248-250
• 12 Prokop A, Stenz R, Koukal C. et al. Kyphoplastie bei hoch thorakalen osteoporotischen Wirbelfrakturen. Chir Prax 2011; 73: 37-46
• 13 Steinmann J, Tingey CT, Cruz G. et al. Biomechanical comparison of unipedicular versus bipedicular kyphoplasty. Spine (Phila Pa 1976) 2005; 30: 201-205
• 14 Chiras J, Sola-Martinez MT, Weill A. et al. Vertébroplasties percutanées. Rev Med Interne 1995; 16: 854-859
• 15 Kasperk C, Nöldge G, Meeder P. et al. [Kyphoplasty: method for minimally invasive treatment of painful vertebral fractures]. Chirurg 2008; 79: 944-950 952–955
• 16 Dachverband Osteologie (DVO). e.V.. Leitlinie Osteoporose 2014. Im Internet: http://www.dv-osteologie.org/dvo_leitlinien/osteoporose-leitlinie-2014 Stand: 13.11.2014
• 17 Ha KY, Kim YH. Risk factors affecting progressive collapse of acute osteoporotic spinal fractures. Osteoporos Int 2013; 24: 1207-1213
• 18 Schnake KJ, Hahn P, Franck A. et al. Development of a classification system (OF-classification) and of a score for therapeutic decision making (OF-score) for osteoporotic thoracolumbar fractures. Eur Spine J 2013; 22: 2590
• 19 Galibert H, Rosat P, Le Gars DP. Note préliminaire sur le traitement des angiomes vertébraux par vertébroplastie acrylique percutanée. Neurochirurgie 1987; 33: 166-168
• 20 Lee MJ, Dumonski M, Cahill P. et al. Percutaneous treatment of vertebral compression fractures: a meta-analysis of complications. Spine (Phila Pa 1976) 2009; 34: 1228-1232
• 21 Li YY, Hsu RW, Cheng CC. et al. Minimally invasive vertebroplasty managed by a two C-arm fluoroscopic technique. Minim Invasive Ther Allied Technol 2007; 16: 350-354
• 22 Li YY, Huang TJ, Cheng CC. et al. A comparison between one- and two-fluoroscopic techniques in percutaneous vertebroplasty. BMC Musculoskelet Disord 2008; 9: 67
• 23 Chang WS, Lee SH, Choi WG. et al. Unipedicular vertebroplasty for osteoporotic compression fracture using an individualized needle insertion angle. Clin J Pain 2007; 23: 767-773
• 24 Papadopoulos EC, Edobor-Osula F, Gardner MJ. et al. Unipedicular balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures: early results. J Spinal Disord Tech 2008; 21: 589-596
• 25 Higgins KB, Harten RD, Langrana NA. et al. Biomechanical effects of unipedicular vertebroplasty on intact vertebrae. Spine (Phila Pa 1976) 2003; 28: 1540-1547 discussion 1548
• 26 Cyteval C, Sarrabère MP, Roux JO. et al. Acute osteoporotic vertebral collapse: open study on percutaneous injection of acrylic surgical cement in 20 patients. AJR Am J Roentgenol 1999; 173: 1685-1690
• 27 Barr JD, Barr MS, Lemley TJ. et al. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine (Phila Pa 1976) 2000; 25: 923-928
• 28 Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine (Phila Pa 1976) 2001; 26: 1511-1515
• 29 Verlaan JJ, van Helden WH, Oner FC. et al. Balloon vertebroplasty with calcium phosphate cement for direct restoration of traumatic thoracolumbar vertebral fractures. Spine (Phila Pa 1976) 2002; 27: 543-548
• 30 Bouza C, López T, Magro A. et al. Efficacy and safety of balloon kyphoplasty in the treatment of vertebral compression fractures: a systematic review. Eur Spine J 2006; 15: 1050-1067
• 31 Taylor RS, Fritzell P, Taylor RJ. Balloon kyphoplasty in the management of vertebral compression fractures: an updated systematic review and meta-analysis. Eur Spine J 2007; 16: 1085-1100
• 32 Wardlaw D, Cummings SR, Van Meirhaeghe J. et al. Efficacy and safety of balloon kyphoplasty compared with non-surgical care for vertebral compression fracture (FREE): a randomised controlled trial. Lancet 2009; 373: 1016-1024
• 33 Edidin AA, Ong KL, Lau E. et al. Mortality risk for operated and nonoperated vertebral fracture patients in the medicare population. J Bone Miner Res 2011; 26: 1617-1626
• 34 Chmielnicki M, McDougall AM, Prokop A. Klinische Kostenanalyse der Ballonkyphoplastie – ist eine kostendeckende Durchführung möglich?. Z Orthop Unfall 2014; 152: 230-233
• 35 Lee JH, Kwon JT, Kim YB. et al. Segmental deformity correction after balloon kyphoplasty in the osteoporotic vertebral compression fracture. J Korean Neurosurg Soc 2007; 42: 371-376
• 36 Fribourg D, Tang C, Sra P. et al. Incidence of subsequent vertebral fracture after kyphoplasty. Spine (Phila Pa 1976) 2004; 29: 2270-2276 discussion 2277
• 37 Hoffmann C, Spiegl UJA, Hauck S. et al. Die ventrale Spondylodese beim älteren Patienten – Overtreatment oder sinnvolle Therapieoption?. Z Orthop Unfall 2013; 151: 257-263
• 38 Kebaish KM, Martin CT, OʼBrien JR. et al. Use of vertebroplasty to prevent proximal junctional fractures in adult deformity surgery: a biomechanical cadaveric study. Spine J 2013; 13: 1897-1903
• 39 Teng MM, Wei CJ, Wei LC. et al. Kyphosis correction and height restoration effects of percutaneous vertebroplasty. AJNR Am J Neuroradiol 2003; 24: 1893-1900
• 40 Frankel BM, Monroe T, Wang C. Percutaneous vertebral augmentation: an elevation in adjacent-level fracture risk in kyphoplasty as compared with vertebroplasty. Spine J 2007; 7: 575-582
• 41 Mudano AS, Bian J, Cope JU. et al. Vertebroplasty and kyphoplasty are associated with an increased risk of secondary vertebral compression fractures: a population-based cohort study. Osteoporos Int 2009; 20: 819-826
• 42 Silverman SL. The clinical consequences of vertebral compression fracture. Bone 1992; 13 (Suppl. 02) S27-S31
• 43 Magerl F, Aebi M, Gertzbein SD. et al. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J 1994; 3: 184-201
• 44 Gejo R, Matsui H, Kawaguchi Y. et al. Serial changes in trunk muscle performance after posterior lumbar surgery. Spine (Phila Pa 1976) 1999; 24: 1023-1028
• 45 Sihvonen T, Herno A, Paljärvi L. et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine (Phila Pa 1976) 1993; 18: 575-581
• 46 Arts MP, Nieborg A, Brand R. et al. Serum creatine phosphokinase as an indicator of muscle injury after various spinal and nonspinal surgical procedures. J Neurosurg Spine 2007; 7: 282-286
• 47 Kumbhare D, Parkinson W, Dunlop B. Validity of serum creatine kinase as a measure of muscle injury produced by lumbar surgery. J Spinal Disord Tech 2008; 21: 49-54
• 48 Charles YP, Zairi F, Vincent C. et al. Minimally invasive posterior surgery for thoraco-lumbar fractures. New trends to decrease muscle damage. Eur J Orthop Surg Traumatol 2011; 22: 1-7
• 49 Grass A, Dickopf A, Rammelt S. et al. Perkutane dorsale versus offene Instrumentation bei Frakturen des thorakolumbalen Übergangs. Unfallchirurg 2006; 109: 297-305
• 50 Wild MH, Glees M, Plieschnegger C. et al. Five-year follow-up examination after purely minimally invasive posterior stabilization of thoracolumbar fractures: a comparison of minimally invasive percutaneously and conventionally open treated patients. Arch Orthop Trauma Surg 2007; 127: 335-343
• 51 Wang HW, Li CQ, Zhou Y. et al. Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases. Chin J Traumatol 2010; 13: 137-145
• 52 Brantley AG, Mayfield JK, Koeneman JB. et al. The effects of pedicle screw fit. An in vitro study. Spine (Phila Pa 1976) 1994; 19: 1752-1758
• 53 Burval DJ, McLain RF, Milks R. et al. Primary pedicle screw augmentation in osteoporotic lumbar vertebrae: biomechanical analysis of pedicle fixation strength. Spine (Phila Pa 1976) 2007; 32: 1077-1083
• 54 Chang MC, Liu CL, Chen TH. Polymethylmethacrylate augmentation of pedicle screw for osteoporotic spinal surgery: a novel technique. Spine (Phila Pa 1976) 2008; 33: E317-E324
• 55 Chmielnicki M, Prokop A, Stenz R. Unstable vertebral body fractures in elderly patients. How stable is percutaneous internal fixation?. J Orthop 2010; 7: 1-10
• 56 Cook SD, Salkeld SL, Stanley T. et al. Biomechanical study of pedicle screw fixation in severely osteoporotic bone. Spine J 2004; 4: 402-408
• 57 Linhardt O, Lüring C, Matussek J. et al. Stability of pedicle screws after kyphoplasty augmentation: an experimental study to compare transpedicular screw fixation in soft and cured kyphoplasty cement. J Spinal Disord Tech 2006; 19: 87-91
• 58 Sarzier JS, Evans AJ, Cahill DW. Increased pedicle screw pullout strength with vertebroplasty augmentation in osteoporotic spines. J Neurosurg 2002; 96 (Suppl. 03) 309-312
• 59 Halvorson TL, Kelley LA, Thomas KA. et al. Effects of bone mineral density on pedicle screw fixation. Spine (Phila Pa 1976) 1994; 19: 2415-2420
• 60 Becker S, Chavanne A, Spitaler R. et al. Assessment of different screw augmentation techniques and screw designs in osteoporotic spines. Eur Spine J 2008; 17: 1462-1469
• 61 Hoppe S, Loosli Y, Baumgartner D. et al. Influence of screw augmentation in posterior dynamic and rigid stabilization systems in osteoporotic lumbar vertebrae: a biomechanical cadaveric study. Spine (Phila Pa 1976) 2014; 39: E384-E389
• 62 Choma TJ, Pfeiffer FM, Swope RW. et al. Pedicle screw design and cement augmentation in osteoporotic vertebrae: effects of fenestrations and cement viscosity on fixation and extraction. Spine (Phila Pa 1976) 2014; 37: E1628-E1632
• 63 Röllinghoff M, Siewe J, Eysel P. et al. Pulmonary cement embolism after augmentation of pedicle screws with bone cement. Acta Orthop Belg 2010; 76: 269-273
• 64 Mueller LA, Mueller LP, Schmidt R. et al. The phenomenon and efficiency of ligamentotaxis after dorsal stabilization of thoracolumbar burst fractures. Arch Orthop Trauma Surg 2006; 126: 364-368
• 65 Wu J, Xu YQ, Chen HF. et al. Percutaneous kyphoplasty combined with the posterior screw-rod system in treatment of osteoporotic thoracolumbar fractures. Indian J Orthop 2013; 47: 230-233
• 66 Zairi F, Court C, Tropiano P. et al. Minimally invasive management of thoraco-lumbar fractures: combined percutaneous fixation and balloon kyphoplasty. Orthop Traumatol Surg Res 2012; 98 (Suppl. 06) S105
• 67 Pflugmacher R, Agarwal A, Kandziora F. et al. Balloon kyphoplasty combined with posterior instrumentation for the treatment of burst fractures of the spine–1-year results. J Orthop Trauma 2009; 23: 126-131
• 68 Fuentes S, Blondel B, Metellus P. et al. Percutaneous kyphoplasty and pedicle screw fixation for the management of thoraco-lumbar burst fractures. Eur Spine J 2010; 19: 1281-1287
• 69 Gu Y, Zhang F, Jiang X. et al. Minimally invasive pedicle screw fixation combined with percutaneous vertebroplasty in the surgical treatment of thoracolumbar osteoporosis fracture. J Neurosurg Spine 2013; 18: 634-640
• 70 Korovessis P, Hadjipavlou A, Repantis T. Minimal invasive short posterior instrumentation plus balloon kyphoplasty with calcium phosphate for burst and severe compression lumbar fractures. Spine (Phila Pa 1976) 2008; 33: 658-667
• 71 Uchida K, Kobayashi S, Matsuzaki M. et al. Anterior versus posterior surgery for osteoporotic vertebral collapse with neurological deficit in the thoracolumbar spine. Eur Spine J 2006; 15: 1759-1767
• 72 Konstantinidis L, Mayer E, Strohm PC. et al. Early surgery-related complications after anteroposterior stabilization of vertebral body fractures in the thoracolumbar region. J Orthop Sci 2010; 15: 178-184
• 73 Kasperk J, Hillmeier J, Nöldge G. et al. Treatment of painful vertebral fractures by kyphoplasty in patients with primary osteoporosis: a prospective nonrandomized controlled study. J Bone Miner Res 2005; 20: 604-612
• 74 Kim WJ, Lee ES, Jeon SH. et al. Correction of osteoporotic fracture deformities with global sagittal imbalance. Clin Orthop Relat Res 2006; 443: 75-93
• 75 Komemushi A, Tanigawa N, Kariya S. et al. Percutaneous vertebroplasty for osteoporotic compression fracture: multivariate study of predictors of new vertebral body fracture. Cardiovasc Intervent Radiol 2006; 29: 580-585
• 76 Uppin AA, Hirsch JA, Centenera LV. et al. Occurrence of new vertebral body fracture after percutaneous vertebroplasty in patients with osteoporosis. Radiology 2003; 226: 119-124
• 77 Lin EP, Ekholm S, Hiwatashi A. et al. Vertebroplasty: cement leakage into the disc increases the risk of new fracture of adjacent vertebral body. AJNR Am J Neuroradiol 2004; 25: 175-180
• 78 Grafe IA, Da Fonseca K, Hillmeier J. et al. Reduction of pain and fracture incidence after kyphoplasty: 1-year outcomes of a prospective controlled trial of patients with primary osteoporosis. Osteoporos Int 2005; 16: 2005-2012
• 79 Okuda S, Oda T, Yamasaki R. et al. Surgical Outcomes of Osteoporotic Vertebral Collapse: A Retrospective Study of Anterior Spinal Fusion and Pedicle Subtraction Osteotomy. Global Spine J 2012; 2: 221-226
• 80 Okamoto Y, Murakami H, Demura S. et al. The effect of kyphotic deformity because of vertebral fracture: a finite element analysis of a 10 degrees and 20 degrees wedge-shaped vertebral fracture model. Spine J 2015; 15: 713-720
• 81 Hato T, Kawahara N, Tomita K. et al. Finite-element analysis on closing-opening correction osteotomy for angular kyphosis of osteoporotic vertebral fractures. J Orthop Sci 2007; 12: 354-360
• 82 Kim MH, Lee AS, Min SH. et al. Risk factors of new compression fractures in adjacent vertebrae after percutaneous vertebroplasty. Asian Spine J 2011; 5: 180-187
• 83 Lunt M, OʼNeill TW, Felsenberg D. et al. Characteristics of a prevalent vertebral deformity predict subsequent vertebral fracture: results from the European Prospective Osteoporosis Study (EPOS). Bone 2003; 33: 505-513
• 84 Butt MF, Farooq M, Mir B. et al. Management of unstable thoracolumbar spinal injuries by posterior short segment spinal fixation. Int Orthop 2009; 31: 259-264
• 85 Logroscino CA, Proietti L, Tamburrelli FC. Minimally invasive spine stabilisation with long implants. Eur Spine J 2007; 18 (Suppl. 01) 75-81
• 86 Altay M, Ozkurt B, Aktekin CN. et al. Treatment of unstable thoracolumbar junction burst fractures with short- or long-segment posterior fixation in magerl type a fractures. Eur Spine J 2007; 16: 1145-1155
• 87 Gurr KR, McAfee PC, Shih CM. Biomechanical analysis of anterior and posterior instrumentation systems after corpectomy. A calf-spine model. J Bone Joint Surg Am 1988; 70: 1182-1191
• 88 Krag MH. Biomechanics of thoracolumbar spinal fixation. A review. Spine (Phila Pa 1976) 1991; 16: S84-S99
• 89 Tezeren G, Kuru I. Posterior fixation of thoracolumbar burst fracture: short-segment pedicle fixation versus long-segment instrumentation. J Spinal Disord Tech 2005; 18: 485-488
• 90 Carl AL, Tromanhauser SG, Roger DJ. Pedicle screw instrumentation for thoracolumbar burst fractures and fracture-dislocations. Spine (Phila Pa 1976) 1992; 17 (Suppl. 08) S317-S324
• 91 Danisa OA, Shaffrey CI, Jane JA. et al. Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes. J Neurosurg 1995; 83: 977-983
• 92 Modi HN, Chung KJ, Seo IW. et al. Two levels above and one level below pedicle screw fixation for the treatment of unstable thoracolumbar fracture with partial or intact neurology. J Orthop Surg Res 2009; 4: 28
• 93 Heini PF, Berlemann U, Kaufmann M. et al. Augmentation of mechanical properties in osteoporotic vertebral bones–a biomechanical investigation of vertebroplasty efficacy with different bone cements. Eur Spine J 2001; 10: 164-171
• 94 Oakland RJ, Furtado NR, Wilcox RK. et al. Preliminary biomechanical evaluation of prophylactic vertebral reinforcement adjacent to vertebroplasty under cyclic loading. Spine J 2009; 9: 174-181
• 95 De Peretti F, Hovorka I, Cambas PM. et al. Short device fixation and early mobilization for burst fractures of the thoracolumbar junction. Eur Spine J 1996; 5: 112-120
• 96 Becker S, Garoscio M, Meissner J. et al. Is there an indication for prophylactic ballon kyphoplasty? A pilot study. Clin Orthop Relat Res 2007; 458: 83-89