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Die zervikale spondylotische Myelopathie

Indikationsstellung für eine chirurgische Therapie

Spondylotic cervical myelopathy

Indication of surgical treatment

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Zusammenfassung

Hintergrund

Die Pathogenese einer zervikalen spondylotischen Myelopathie (ZSM) ist oft multifaktoriell. Aus diesem Grund bedarf die Therapie dieser Erkrankung einer sehr differenzierten chirurgischen Herangehensweise, um die auslösende Pathologie adäquat zu adressieren. Zudem wird in der Literatur das ideale Timing zur Durchführung einer Operation kontrovers diskutiert.

Ziel der Arbeit

Ziel dieser Übersichtsarbeit ist, die auf die Wahl der therapeutischen Strategie Einfluss nehmenden Faktoren zu benennen und zu versuchen, diese in einem Algorithmus als Entscheidungshilfe für die therapeutischen Strategien zusammenzufassen. Es soll versucht werden, die Schwellenwerte für die Indikation einer chirurgischen Therapie anhand der publizierten Literatur zu definieren.

Material und Methoden

Anhand der publizierten Daten werden die Einflussfaktoren für die Prognose der ZSM herausgearbeitet. Damit soll die Empfehlung über den bestmöglichen Zeitpunkt der chirurgischen Therapie definiert werden. Im Weiteren werden die chirurgischen Therapieansätze ausgearbeitet.

Ergebnisse

Zu den prognostisch ungünstigen Faktoren für die Verschlechterung der ZMS gehören in erster Linie die zirkumferenzielle Rückenmarkkompression, ein kräftiges und scharf begrenztes Myelopathiesignal in der T2-gewichteten MRT-Sequenz und die segmentale Instabilität auf Höhe der Myelopathie. Die wichtigsten Faktoren, die eine Rolle in der Entscheidung über das operative Vorgehen spielen, sind das sagittale Profil der HWS, die Ausdehnung der Myelopathie, das Ausmaß der Stenose und die Lokalisation der die Myelopathie auslösenden Pathologie. Auch zuvor bestehende Nackenschmerzen und Voroperationen dürfen nicht außer Acht gelassen werden und müssen im Rahmen der Indikationsstellung abgefragt werden.

Diskussion

Anhand der durchgeführten Literaturrecherche konnte ein therapeutischer Algorithmus erstellt werden, der im klinischen Alltag als Entscheidungshilfe dienen soll.

Abstract

Background

The pathogenesis of cervical spondylotic myelopathy (CSM) is often multifactorial. Hence, the treatment of this disease requires a differentiated surgical approach in order to adequately address the underlying pathology.

Purpose

The aim of this review is to identify factors that influence the choice of treatment strategy and to summarize them in an algorithm that serves as a decision aid in choosing the optimal indication for surgical treatment. An attempt is made to define the threshold values for the indication of surgical treatment and to discuss the ideal timing for performing surgery.

Materials and methods

On the basis of the published data, the influencing factors on the prognosis of CSM, as well as surgical approaches are discussed.

Results

Circumferential spinal cord compression, a sharply defined myelopathy signal in the T2-weighted MRI sequence, and segmental instability at the level of the myelopathy signal mean an unfavorable prognosis for the worsening of CSM. The most important factors that influence the choice of the surgical access point are the sagittal profile of the cervical spine, the extent of myelopathy, the extent of stenosis, and the location of the myelopathy-inducing pathology. Previously existing neck pain and prior cervical surgery must also be considered.

Discussion

On the basis of the research carried out, we developed an algorithm that could serve as an aid in choosing the right treatment in the setting of cervical spondylotic myelopathy.

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Abbreviations

AO:

Arbeitsgemeinschaft für Osteosynthesefragen

BS:

Bandscheibe

HWK:

Halswirbelkörper

HWS:

Halswirbelsäule

JOA:

Japanese Orthopaedic Association

MEP:

Motorisch evozierte Potenziale

mJOA:

Modifizierter Japanese Orthopaedic Association Score

MRT:

Magnetresonanztomographie

NDI:

Neck Disability Index

PEEK:

Polyetheretherketon

SF-36:

Short Form 36

SSEP:

Somatosensibel evozierte Potenziale

ZSM:

Zervikale spondylotische Myelopathie

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Authors and Affiliations

  1. Zentrum für Wirbelsäulenchirurgie, Klinik für Orthopädie, Unfallchirurgie und Paraplegiologie, Universitätsklinikum Heidelberg, Schlierbacher Landstr. 200a, 69118, Heidelberg, Deutschland

    W. Pepke, H. Almansour & M. Akbar

  2. Wirbelsäulenzentrum, St. Josefs-Hospital, Beethovenstr. 20, 65189, Wiesbaden, Deutschland

    M. Richter

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  1. W. Pepke
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  2. H. Almansour
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  3. M. Richter
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  4. M. Akbar
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Correspondence to W. Pepke.

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W. Pepke, H. Almansour, M. Richter und M. Akbar geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Pepke, W., Almansour, H., Richter, M. et al. Die zervikale spondylotische Myelopathie. Orthopäde 47, 474–482 (2018). https://doi.org/10.1007/s00132-018-3566-z

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