Minimalinvasive Versorgung von thorakolumbalen Wirbelfrakturen: Möglichkeiten und Grenzen

Abstract

Minimally invasive surgery for vertebral fractures means less approach-related morbidity, decreased postoperative pain and rapid mobilization of patients. Such procedures can be performed even in elderly patients. However, along with the many advantages, minimally invasive procedures are technically demanding, require sophisticated tools and there is a learning curve for surgeons. Intraoperative visualization is often possible only radiologically and implants are generally much more expensive. Using the data from some 1,000 vertebral fracture cases treated over the past 3.5 years, we have developed a differentiated treatment concept, depending on the age of the patient and the fracture characteristics, which are presented here. Unstable fractures with involvement of the posterior edge are stabilized from a posterior approach, percutaneously with a fixator. In patients under 60 years, monoaxial screws with inserted rods (top loading) are used with which distraction and restoration of lordosis are also possible. Patients over 60 years are treated percutaneously with a polyaxial sextant system with rods inserted to avoid avulsion of the pedicle screws from the vertebral body. To avoid cutting through the vertebra, the fenestrated screws can be augmented with cement. If a vertebral defect remains after posterior treatment, anterior fusion can also be performed endoscopically with an iliac crest bone graft and an anterior plate if necessary. In older patients, often kyphoplasty is sufficient here. For recent, stable osteoporotic fractures with enhancement of the short time inversion-recovery (STIR) T2 sequence on magnetic resonance imaging and severe pain despite analgesics kyphoplasty is performed. This is possible even in high thoracic fractures to T3 using thinner balloons. In 0.34% (2 out of 564) of cases post-operative neurological deficits were observed after cement extravasation. © Springer-Verlag 2012.