Behandlungsergebnisse bei Patienten mit lumbaler Spinalstenose nach dynamischer Stabilisierung mittels interspinöser Implantate
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Philipps-Universität Marburg
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Abstract
A narrowed spinal canal is called lumbar spinal stenosis. Often this painful disorder is caused by degenerative changes of the spine. Primary a conservative, stabilizing therapy is attempted. If the symptoms worsen or a significant deterioration of the quality of life occurs the conservative therapy failured and an operative rehabilitation is indicated.
Due to demographic changes, most of the patients undergoing spine surgery are elderly.
The crucial step of this operation is to decompress the corresponding segment. This can be combined with advanced procedures such as laminectomy and facetectomy. However, in this case there is the risk of instability, which in turn increases the strain in the corresponding segment, and thus promotes its degenerative changes.
To avoid this problem, a fusion of this segment can be performed. This fusion is problematic, as it completely eliminates the flexibility in the corresponding region and increases the degenerative changes in the adjacent segments.
A solution to this problem may be segmental distraction and decompression via dynamic stabilization of the spine. Here the vertebral bodies are not fused and allow some residual motion. To enable this, implants such as Wallis, In-SWing, Le U, DIAM, and X-Stop can be used.
Aim of the study: Interspinous implants (Wallis, X-Stop, Le U, InSWing) are and were often applied in surgery of the lumbar spine. Despite this, there are only very few clinicalradiological studies published todate.
From March 2008 to July 2009, 33 patients being operatively supplied with aforementioned lumbar interspinous implants in the Helios Rosmann Hospital Breisach, Germany, due to lower back pain and / or sciatica, a part of them with significant palsy or sensory disturbances, were included in the study. Aim of this retrospective study was mainly to investigate the clinical and radiological results on the background of a kinematic analysis concerning the lumbar functional and ajacent segment’s motion behaviour.
Materials and methods: The patients were examined clinically and radiologically prior and after surgery, as well as 6-12 months after the operation. The clinical situation was assessed via Visual Analog Scale (VAS) and Oswestry Disability Index (ODI).
The radiological examination included radiographs of the lumbar spine a. p. and lateral functional images in inclination and reclination prior to surgery and lateral functional images at follow-up.
Three adjacent segments were examined closely and the following points determined: Angles of vertebral body endplates, distances of the posterior corner points of the vertebral bodies and of the spinous processes, each in inclination and reclination in the operated segment as well as in the segments above and below the operated segment, before and after surgery.
Results: 33 patients (14 females (42.4%) and 19 males (57.6%)) with instrumentation above S1 were included in the study. The mean age of the en-tire group at time of surgery was 62.1 ± 13.7 years, the mean age of the fe-male patients was 59.6 ± 16.0 years and of the male patients it amounted to 65.6 ± 11.6 years. The age of the patients prior to surgery ranged between 20 and 85 years.
8 patients were taken care of bi-segmentally and 25 patients were operated in one segment only. The average pain level reached at follow-up was 3.5 on the VAS as opposed to 7.8 preoperatively. 30 out of 33 patients reported a significant reduction in pain, 21 of 24 reported the sensory disturbances eliminated and in 12 of 13 patients their spinal claudication existed no longer. An overall operation satisfaction of 81.8% is more than acceptable in the field of spinal surgery. In 3 patients the implant had to be removed due to persistent complaints and was subsequently replaced by a posterolateral spinal fusion. No radiologically detectable implant dislocation occurred during follow-up.
The implants reduced the range of motion in the segment with the device and significantly reduced its lordosis over the entire motion amplitude. Concordantly, the lordosis in the upper and lower adjacent segment was at least partially significantly increased. The entire range of motion of the complex of instrumented plus adjacent segments remained virtually unchanged. This implies that interspinous implants not only influence the operated segment but have detectable effects upon the kinematics and sagittal balance of the entire lumbar spine. This study shows these effects for the first time ever in vivo. Effects upon the coupled sagittal translation of the segments in flexion and extension can be indirectly assumed but not directly be proven on the basis of the data presented.
Conclusion:
Interspinous implants, not unlike fusion implants, surprisingly create complex and radiologically detectable effects in case of segmental stabilization after decompression for lumbar stenosis or disc prolapse. In comparison with the literature their clinical results are at least similarly good as decompressive standalone procedures. They must not be excluded up front as a useful therapy option in the future as long as well accepted exclusion criteria are respected. Further prospective randomized studies in larger cohorts are nevertheless advisable.
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Created: 2016Issued: 2017-08-28Updated: 2017-08-29
Faculty
Medizin
Publisher
Philipps-Universität Marburg
Language
ger
Data types
DoctoralThesis
DFG-subjects
interspinöse Implantatelumbale Spinalstenosedynamische Stabilisierung
DDC-Numbers
610
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Ajez, Yasin: Behandlungsergebnisse bei Patienten mit lumbaler Spinalstenose nach dynamischer Stabilisierung mittels interspinöser Implantate. : Philipps-Universität Marburg 2017-08-28. DOI: https://doi.org/10.17192/z2017.0453.