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Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule

Teil II: Operation und röntgenologische Befunde

Operative treatment of traumatic fractures of the thorax and lumbar spine

Part II: surgical treatment and radiological findings

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Zusammenfassung

Die Arbeitsgemeinschaft Wirbelsäule (AG WS) der Deutschen Gesellschaft für Unfallchirurgie (DGU) berichtet im vorliegenden zweiten Teil ihrer internetbasierten multizentrischen Sammelstudie (MCS II) zur Behandlung von Verletzungen der gesamten Brust- und Lendenwirbelsäule über die Operation, Behandlungsdetails und radiologische Befunde von insgesamt 865 Patienten.

Es handelte sich um 158 (18,3%) Verletzungen der Brustwirbelsäule (BWS), 595 (68,8%) Verletzungen des thorakolumbalen Übergangs (TLÜ) und 112 Verletzungen der Lendenwirbelsäule (LWS). 733 Patienten wurden operativ versorgt (OP). Es wurden 52 Patienten mit einem nichtoperativen Verfahren (KONS) behandelt. 69 Patienten erhielten eine Kypho- oder Vertebroplastie (PLASTIE).

In der Behandlungsgruppe OP wurden 380 Patienten (51,8%) isoliert dorsal (DORSAL), 34 (4,6%) ventral (VENTRAL) und 319 (43,5%) kombiniert dorsoventral (KOMBI) stabilisiert.

Im Zuge dorsaler und/oder kombinierter Verfahren wurden überwiegend auf winkelstabile Fixateursysteme (86–97%) und ventrale winkelstabile Platten (51,1%) zur Stabilisierung von ein bis zwei Segmentläsionen (72,7%) zurückgegriffen. Insgesamt 188-mal (53,3%) wurden Wirbelkörperersatzimplantate (Cages) durch einen ventralen Zugang zur BWS oder TLÜ überwiegend endoskopisch (67,4%) implantiert. Die durchschnittliche Operationsdauer bei dorsalem (152 min) und ventralem (208 min) Eingriff war kürzer als die der kombinierten Operationen (298 min; p<0,001). Der Blutverlust betrug nach kombiniertem Eingriff durchschnittlich 959 ml gegenüber 650 ml bei dorsalen und 534 ml bei ventralen Verfahren (p<0,001). Computerassistierte Systeme zur intraoperativen Navigation wurden 95-mal eingesetzt. Bei 58,7% aller Patienten lag präoperativ eine unfallbedingte Spinalkanaleinengung von durchschnittlich 36% (5–95%) vor. Die durchschnittliche relative Enge des Spinalkanals lag bei Patienten mit komplettem QS bei 70%, mit inkomplettem QS bei 50% und bei Patienten ohne neurologische Ausfälle bei 20% (p<0,001). In der Behandlungsgruppe PLASTIE lag die durchschnittliche Operationsdauer bei 50 min (18–145 min), um jeweils einen (n=59) oder zwei (n=10) Wirbelkörper zu augmentieren. Zur nichtoperativen Behandlung wurde am häufigsten auf Drei-Punkt-Korsetts (n=36) zurückgegriffen, die für einen Zeitraum von 6 bis 12 Wochen verordnet wurden.

Während der stationären Behandlung verbesserten sich 93 von insgesamt 195 (44,7%) Patienten mit initialer neurologischer Begleitverletzung um mindestens eine Frankel-/ASIA-Stufe. Demgegenüber standen zwei (0,2%) neurologische Verschlechterungen. Die höchste Rate kompletter Querschnittslähmungen (n=36; 23%) wurde als Folge von Verletzungen der Brustwirbelsäule beobachtet.

Neun Patienten (1%) verstarben während der Behandlung. Es wurden 105 (14,3%) Verläufe mit intra- (n=56) und/oder postoperativen (n=69) Komplikationen gezählt. Die häufigste intraoperative Komplikation waren Blutungen (n=35; 4,8%). Die relative Häufigkeit intraoperativer Komplikationen war größer nach kombinierter Behandlung (n=34; 10,7%) als nach isoliert dorsaler Operation (n=22; 5,9%; p=0,021). Postoperativ wurden Wundheilungsstörungen in 14 Fällen (1,9%) registriert.

Mit Ausnahme der nichtoperativen Behandlung wurde mit allen Behandlungsmethoden eine Korrektur der unfallbedingten radiologischen Fehlstellung unterschiedlichen Ausmaßes erreicht. Unter Berücksichtigung relevanter Einflüsse, wie z. B. Frakturtyp, Patientenalter und Fehlstellung zum Unfallzeitpunkt, wurden zwischen den operativen Behandlungsgruppen (DORSAL vs. KOMBI) keine statistisch signifikanten Unterschiede (p=0,34; ANOVA) der unmittelbar postoperativen röntgenologischen Ergebnisse beobachtet.

Abstract

The Spine Study Group (AG WS) of the German Trauma Association (DGU) presents its second prospective Internet-based multicenter study (MCS II) for the treatment of thoracic and lumbar spinal injuries. This second part of the study report focuses on the surgical treatment, course of treatment, and radiological findings in a study population of 865 patients.

A total of 158 (18,3%) thoracic, 595 (68,8%) thoracolumbar, and 112 (12,9%) lumbar spine injuries were treated. Of these, 733 patients received operative treatment (OP group). Fifty-two patients were treated non-operatively and 69 patients were treated with kyphoplasty/vertebroplasty without additional instrumentation (Plasty group).

In the OP group, 380 (51.8%) patients were instrumented from a posterior (dorsal) position, 34 (4.6%) from an anterior (ventral) position, and 319 (43.5%) cases with a combined posteroanterior procedure.

Angular stable internal spine fixator systems were used in 86–97% of the cases for posterior and/or combined posteroanterior procedures. For anterior procedures, angular stable plate systems were used in a majority of cases (51.1%) for the instrumentation of mainly one or two segment lesions (72.7%).

In 188 cases (53,3%), vertebral body replacement implants (cages) were used and were mainly implanted via endoscopic approaches (67,4%) to the thoracic spine and/or the thoracolumbar junction. The average operating time was 152 min in posterior-, 208 min in anterior-, and 298 min in combined postero-anterior procedures (p<0,001). The average blood loss was highest in combined operations, measuring 959 ml vs. 650 ml in posterior vs. 534 ml in anterior operations (p<0,001).

Computer-assisted intraoperative navigation systems were used in 95 cases.

At the time of hospital admission, 58,7% of the patients had spinal canal narrowing of an average of 36% (5–95%) at the level of their injury. The average spinal canal narrowing in patients with a complete spinal cord injury (Frankel/ASIA A) was calculated to be 70%, vs. 50% in patients with incomplete neurologic deficits (Frankel/ASIA B–D), and 20% in patients without neurologic deficits (Frankel/ASIS E; p<0,001).

The average procedure in the plasty treatment subgroup was 50 min (18–145 min) to address one (n=59) or two (n=10) injured vertebral bodies.

In patients with nonoperative treatment mainly three-point-corsets (n=36) were administered for a duration of 6–12 weeks.

During their hospital stay 93 of 195 (44,7%) patients with initial neurologic deficits improved at least one Frankel/ASIA grade until the day of discharge. Two patients (0,2%) showed a neurologic deterioration. The highest rate of complete spinal cord injury (n=36, 23%) was associated with thoracic spine injuries.

Nine (1%) patients died during the initial course of treatment. A total of 105 (14,3%) cases with intraoperative (n=56) and/or postoperative complications (n=69) were registered. The most common intraoperative complication was bleeding (n=35, 4,8%). A higher relative frequency of intraoperative complications was noticed in combined (n=34, 10,7%) vs. isolated posterior (n=22, 5,9%; p=0,021) procedures. The most common postoperative complication was associated with wound healing problems in 14 (1,9%) patients.

Except in the non-operative treatment subgroup, a correction of the posttraumatic measured radiological deformity was achieved to a different extent within every treatment subgroup. There were no statistically significant differences between the postoperative radiological results of the treatment subgroups (dorsal vs. combination), taking into consideration the influence of relevant parameters such as different fracture types, patient age, and the amount of posttraumatic deformity (p=0,34, ANOVA).

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Authors and Affiliations

  1. Universitätsklinik für Unfallchirurgie und Sporttraumatologie, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich

    M. Reinhold, C. Knop & M. Blauth

  2. Berufsgenossenschaftliche Unfallklinik Murnau, Murnau, Deutschland

    R. Beisse & V. Bühren

  3. AO Clinical Investigation and Documentation (AOCID), Dübendorf, Schweiz

    L. Audigé

  4. Centrum für muskuloskeletale Chirurgie, Charité Berlin, Berlin, Deutschland

    F. Kandziora

  5. Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum, Homburg/Saar, Deutschland

    A. Pizanis

  6. Unfallkrankenhaus Klagenfurt, Klagenfurt, Österreich

    R. Pranzl

  7. Universitätsklinik für Unfallchirurgie Mainz, Mainz, Deutschland

    E. Gercek

  8. Universitätsklinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Ulm, Deutschland

    M. Schultheiss

  9. Klinik und Poliklinik für Unfallchirurgie der Universität Würzburg, Würzburg, Deutschland

    A. Weckbach

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  1. M. Reinhold
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  2. C. Knop
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Correspondence to M. Reinhold.

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Prospektive internetbasierte multizentrische Sammelstudie (MCS II) der Arbeitsgemeinschaft Wirbelsäule (AG WS) der Deutschen Gesellschaft für Unfallchirurgie (DGU)

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Reinhold, M., Knop, C., Beisse, R. et al. Operative Behandlung traumatischer Frakturen der Brust- und Lendenwirbelsäule. Unfallchirurg 112, 149–167 (2009). https://doi.org/10.1007/s00113-008-1538-1

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