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Ventrale Skolioseoperationen

Stand der Technik und Vergleich mit dorsalen Verfahren

Anterior scoliosis surgery

State of the art and a comparison with posterior techniques

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Zusammenfassung

Als Goldstandard der Formkorrektur und Stabilisierung von Skoliosen über den vorderen Zugangsweg wurde über mehr als 2 Jahrzehnte die ventrale Derotationsspondylodese (VDS) nach Zielke als maßgebliche Weiterentwicklung der Dwyer-Instrumentation (DI) angesehen. Sie ermöglicht als erstes Implantatsystem eine effektive dreidimensionale Formkorrektur. Nachteilig sind die geringen internen Stabilisierungseigenschaften des Implantats mit dem Risiko des Stabbruches und der Pseudarthrose, die eine langmonatige Ruhigstellung im Rumpfgips oder Korsett notwendig machen. Durch die Entwicklung primärstabiler ventraler Einstab- und insbesondere Doppelstabsysteme können diese Nachteile mittlerweile vollständig eliminiert werden. Thorakoskopische Skolioseoperationen haben sich mit einem Anteil von <2% wegen langer Operationszeiten und hoher Lernkurve nicht entscheidend durchsetzen können.

Dorsal galt über lange Zeit das Cotrel-Dubousset-Instrumentarium (CDI), ein hakengetragenes polysegmental angreifendes Doppelstabsystem als „state of the art“, da es die Nachteile des weitgehend eindimensional korrigierenden, nicht primärstabilen Harrington-Systems (HI) weitgehend eliminierte, wenngleich eine effektive Derotation nicht möglich war. Bei den dorsalen Verfahren gibt es zzt. sowohl für den Lumbal- als auch Thorakalbereich einen starken Trend weg von hakengetragenen, polysegmental angreifenden Doppelstabsystemen zu transpedikulär segmental fixierten Doppelstabsystemen mit dem Vorteil kürzerer Fusionsbezirke, besserer Korrektur und geringerem Korrekturverlust im Nachbeobachtungszeitraum.

Vorteile moderner ventraler Instrumentationssysteme sind im Vergleich zu modernen dorsalen transpedikulär getragenen Doppelstabsystemen insbesondere der geringere Blutverlust, die bessere Derotation, der im Trend immer noch kürzere Fusionsbereich und der bessere Einfluss auf das Profil der Wirbelsäule bei hypokyphotischen Thorakalskoliosen. Unsere Daten belegen auch eine bessere Spontankorrektur der lumbalen Nebenkrümmung bei selektiver Korrektur von Thorakalskoliosen (Lenke-Typ 1B+C), obwohl andere Studien keine signifikanten Unterschiede finden konnten. Nach unserer Erfahrung ist auch das neurologische Risiko geringer, selbst wenn die Morbiditäts- und Mortalitätsstatistiken der „Scoliosis Research Society“ dieses in den letzten Jahren nicht mehr belegt haben. Nachteilig ist nach neueren Untersuchungen der negativere Effekt ventraler (transthorakaler) Eingriffe auf die Lungenfunktion, die sich im Vergleich zu dorsalen Verfahren postoperativ langsamer erholt und nicht ganz die Werte dorsaler Verfahren erreicht. Neueste Untersuchungen belegen aber auch für dorsale pedikelschraubengetragene Korrekturen einen lordosierenden Effekt mit negativem Einfluss auf die Lungenfunktion

Abstract

For more than 2 decades ventral derotation spondylodesis (Zielke VDS) as a major improvement over Dwyer instrumentation (DI) was the gold standard of instrumented curve correction and stabilization from the anterior approach. As the first available system it enables a true three-dimensional curve correction. A disadvantage is the low internal stabilization capability with a need for long-term external stabilization by means of cast and brace treatment postoperatively. Meanwhile with the development of modern single and dual solid rod systems these disadvantages can be avoided completely. Video-assisted (thoracoscopic) anterior scoliosis surgery accounts for less than 2% of anteriorly treated scoliosis cases, mainly due to a long operating time and significant learning curve.

From the posterior approach the Cotrel-Dubousset instrumentation (CDI) as a polysegmentally attached posterior hook threaded dual rod system used to be state of the art for a long time, since it eliminated the disadvantages of Harrington instrumentation (HI) in terms of only one-dimensional correction and low stabilization capabilities. However even with CDI effective derotation was impossible. In posterior scoliosis surgery there is a strong trend away from hook systems towards transpedicular segmentally fixed dual rod systems not only in the lumbar spine but also in the thoracic area. Advantages of these newer techniques are shorter fusion, improved correction, and less loss of correction over time.

Advantages of modern anterior instrumentation systems in comparison to posterior transpedicular instrumented dual rod systems are less blood loss, better derotation, slightly shorter fusion levels, and a better influence on sagittal plane control or improvement especially for hypokyphotic thoracic scoliosis cases. Our data also document a superior spontaneous correction of the lumbar curve after selective anterior instrumented correction (Lenke 1B+C), although other studies could not find significant differences. In our experience the neurological risk of anterior instrumented correction is also lower than that of posterior scoliosis surgery, although the morbidity and mortality data of the Scoliosis Research Society could not prove that anymore in recent years. A negative effect of anterior transthoracic scoliosis surgery in comparison to posterior surgery is a more negative effect on lung function, which improves slower after surgery and does not quite reach the levels of posterior surgery at follow-up. But new data on posterior segmental transpedicular correction and fusion also prove a lordosating effect with negative effect on lung function.

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  1. Klink für Wirbelsäulenchirurgie mit Skoliosezentrum, Klinikum Neustadt, Am Kiebitzberg 10, 23730, Neustadt, Deutschland

    H. Halm, A. Richter, B. Thomsen, M. Köszegvary, M. Ahrens & M. Quante

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  1. H. Halm
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Halm, H., Richter, A., Thomsen, B. et al. Ventrale Skolioseoperationen. Orthopäde 38, 131–145 (2009). https://doi.org/10.1007/s00132-008-1365-7

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