Zervikale Myelopathie: Wann operieren?

Zusammenfassung

Die zervikale spondylogene Myelopathie (ZSM) führt zu einer funktionellen Schädigung des Rückenmarkes. Der klinische Verlauf ist variabel und zeitlich schwer einschätzbar. Die anhaltende Kompression des Rückenmarkes durch Bandscheibengewebe, dorsale Osteophyten oder ein verkalktes hinteres Längsband verursacht sowohl eine direkte mechanische Schädigung des Rückenmarkes als auch eine sekundäre vaskuläre Schädigung infolge der Beeinträchtigung seiner Perfusion. Bei 20 – 60 % der Patienten tritt im Verlauf eine Verschlechterung der neurologischen Symptomatik auf. Konservative Behandlungsoptionen ermöglichen es „Zeit zu gewinnen“, jedoch keine ursächliche Therapie der Myelopathie. Hingegen kann der operative Eingriff zu einer Rückbildung der neurologischen Symptome und somit zu einer besseren Lebensqualität führen. Das operative Vorgehen ist abhängig von verschiedenen Faktoren: Ausmaß und Lokalisation der Stenose, Stabilität und Alignment der Wirbelsäule. Ein hohes Lebensalter, eine lange Symptomdauer und eine schlechte neurologische Ausgangssituation sind prognostisch negative Faktoren. Bei Patienten mit progredienter Myelopathie und/oder zusätzlichen Risikofaktoren wird deshalb eine frühe operative Behandlung empfohlen.

Abstract

Cervical spondylotic myelopathy (CSM) leads to functional impairment of the spinal cord. The clinical course is variable and difficult to predict. Continuing compression of the spinal cord by disc material, posterior osteophytes or an ossified posterior longitudinal ligament results in direct mechanical impairment and also leads to secondary injury by disturbance of the vascular supply. 20 % to 60 % of all patients will deteriorate neurologically over time. With conservative treatment the patient can gain some time but it does not effect the natural course of CSM. Operative treatment, however, can reduce neurological symptoms and improve a patients quality of life. The surgical approach depends on several individual factors as location and extension of spinal cord compression, stability and alignment of the cervical spine. Age, baseline myelopathy severity and long duration of symptoms are negative predictors for surgical outcome. In case of progressive myelopathy and/or additional risk factors an early operative intervention is recommended.

Schlüsselwörter

Zervikale Spinalkanalstenose - Halswirbelsäule - zervikale Myelopathie - chirurgische Therapie

Keywords:

Cervical spinal stenosis - cervical spine - cervical myelopathy - surgical treatment

• Literaturverzeichnis

• 1 Kalsi-Ryan S, Karadimas S, Fehlings M. Cervical spondylotic myelopathy: the clinical phenomenon and the current pathobiology of an increasingly prevalent and devastating disorder. Neuroscientist 2013; 19: 409-421
• 2 Karadimas SK, Erwin WM, Ely CG. et al. Pathophysiology and natural history of cervical spondylotic myelopathy. Spine 2013; 22: S21-S36
• 3 Karadimas SK, Gatzounis G, Fehlings M. Pathobiology of cervical spondylotic myelopathy. Eur Spine J 2015; 24: S132-S138
• 4 Nouri A, Tetreault L, Singh A. et al. Degenerative cervical myelopathy. Epidemiology, genetics, and pathogenesis. Spine 2015; 40: E675-E693
• 5 Matz PG, Anderson PA, Holly LT. et al. The natural history of cervical spondylotic myelopathy. J Neurosurg Spine 2009; 11: 104-111
• 6 Matsunaga S, Komiya S, Toyama Y. Risk factors for development of myelopathy in patients with cervical spondylotic cord compression. Eur Spine J 2015; 24: S142-S149
• 7 Bednarik J, Kadanka Z, Dusek L. et al. Presymptomatic spondylotic cervical cord compression. Spine 2004; 29: 2260-2269
• 8 Kadanka Z, Mares M, Bednarik J. et al. Approaches to spondylotic cervical myelopathy. Conservarive versus surgical results in a 3-year follow-up study. Spine 2002; 27: 2205-2211
• 9 Rhee JM, Shamji MF, Erwin M. et al. Nonoperative management of cervical myelopathy. A systematic review. Spine 2013; 22: S55-S56
• 10 Tetreault LA, Kopjar B, Nouri A. et al. The modified Japanese Orthopaedic Association scale: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy. Eur Spine J DOI: 10.1007/s00586-016-4660-8.
• 11 Tetreault LA, Ibrahim A, Cote P. et al. A systematic review of clinical and surgical predictors of complications following surgery for degenerative cervical myelopathy. J Neurosurg Spine 2016; 24: 77-99
• 12 Tetreault LA, Tan G, Kopjar B. et al. Clinical and Surgical Predictors of Complications Following Surgery for the Treatment of Cervical Spondylotic Myelopathy: Results From the Multicenter, Prospective AOSpine International Study of 479 Patients. Neurosurgery 2016; 79: 33-44
• 13 Fehlings MG, Wilson JR, Kopjar B. et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am 2013; 95: 1651-1658
• 14 Fehlings MG, Ibrahim A, Tetreault L. et al. A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multicenter AOSpine International study on 479 patients. Spine 2015; 40: 1322-1328
• 15 Holly LT, Matz PG, Anderson PA. et al. Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy. J Neurosurg Spine 2009; 11: 112-118
• 16 Tetreault LA, Karpova A, Fehlings M. Predictors of outcome in patients with degenerative cervical spondylotic myelopathy undergoing surgical treatment: results of a systematic review. Eur Spine J 2015; 24: S236-S251
• 17 Tetreault LA, Kopjar B, Vaccaro A. et al. A clinical prediction model to determine outcomes in patients with cervical spondylotic myelopathy undergoing surgical treatment. Data from the prospective, multi-center AOSpine North America Study. J Bone Joint Surg Am 2013; 95: 1659-1666
• 18 Tetreault LA, Cote P, Kopjar B. et al. A clinical prediction model to assess surgical outcome in patients with cervical spondylotic myelopathy: internal and external validations using the prospective multicenter AOSpine North American and international datasets of 743 patients. Spine J 2015; 15: 388-397