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Degenerative Erkrankungen der Lendenwirbelsäule

Bandscheibenersatz als Alternative zur Spondylodese?

Degenerative disorders of the lumbar spine

Total disc replacement as an alternative to lumbar fusion?

  • Leitthema
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Zusammenfassung

Lumbale Spondylodesen bei degenerativen Erkrankungen haben einen festen Platz im „chirurgischen Portfolio“ von Wirbelsäulenzentren. Der klinische Nutzen und das Risikopotential sind jedoch seit Jahren Gegenstand kontroverser Diskussionen, da bis heute evidenzbasierte Daten hierzu spärlich sind.

In den letzten Jahren ist der künstliche Bandscheibenersatz zu einer möglichen chirurgischen Alternative herangereift. Da zu dieser Technologie weder verlässliche Langzeitergebnisse vorliegen noch ausreichend theoretisches Wissen vorhanden ist, erhebt der vorliegend Artikel eine kritische Bestandsaufnahme. Die 5 zurzeit weltweit verfügbaren oder bereits zugelassenen Implantatsysteme (SB Charité, Prodisc II L, Maverick; Flexicore, Mobidisc) sind als „Erstgenerationsimplantate“ zu betrachten. Die bisher publizierten, überwiegend guten klinischen Frühergebnisse sind fast ausschließlich in empirischen und unkontrollierten Studien erhoben. Die morphologischen und klinischen Auswirkungen der sehr unterschiedlichen sowohl biomechanischen als auch Design- und Materialkonzepte sind bisher ungenügend untersucht. Über ein sinnvolles Indikationsspektrum besteht gegenwärtig kein internationaler Konsensus. Gleiches gilt für die optimale (möglichst minimal-invasive) Zugangsstrategie. Die Komplikationsraten sind tendenziell etwas niedriger als bei Spondylodesen, reproduzierbare Revisionsstrategien sind bisher nicht publiziert.

Der lumbale Bandscheibenersatz hat eine neue Ära der Wirbelsäulenchirurgie eröffnet deren Nutzen für den Patienten bisher unbewiesen ist. Die Technologie sollte daher nur von entsprechend ausgebildeten Chirurgen durchgeführt werden. Bis zum Vorliegen evidenzbasierter Daten sollte eine, über die derzeitige klinische Routine hinausgehende, engmaschige und kritische postoperative Ergebniskontrolle erfolgen.

Abstract

Spinal fusion is accepted worldwide as a therapeutic option for the treatment of degenerative disorders of the lumbar spine. Because there are only few evidence-based data available supporting the usefulness of lumbar spinal fusion, its questionable benefit as well as the potential for complications are the reasons for an ongoing discussion.

In recent years, total disc replacement with implants has emerged as an alternative treatment. Although early results are promising, there is still a lack of evidence-based data as well as of long-term results for this technology. This article gives a critical update on the implant systems currently in use (SB Charité, Prodisc II L, Maverick, Flexicore, Mobidisc), which all have to be considered as “first-generation” implants. Morphological and clinical sequelae of the different biomechanical properties, designs, and materials have not yet been sufficiently investigated. There is no international consensus on the indication spectrum and on the preoperative diagnosis of discogenic low back pain. The same is true for the (minimally invasive) surgical access strategies. Complication rates seem to be somewhat lower compared to spinal fusion techniques. There are no standardized revision concepts in cases of implant failure.

Lumbar disc replacement has opened a new era in spinal surgery with a still unproven benefit for the patient. It is strongly recommended that these techniques should only be applied by experienced and well-trained spine surgeons. Until evidence-based data are available, all patients should be treated under scientific study conditions with close postoperative follow-up.

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Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen.

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  1. Wirbelsäulenzentrum, Orthozentrum, München

    H. M. Mayer

  2. Wirbelsäulenzentrum, Orthozentrum, Harlachinger Straße 51, 81547, München

    H. M. Mayer

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Mayer, H.M. Degenerative Erkrankungen der Lendenwirbelsäule. Orthopäde 34, 1007–1020 (2005). https://doi.org/10.1007/s00132-005-0836-3

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