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OP-Journal 2018; 34(02): 118-126
DOI: 10.1055/a-0574-3131
Fachwissen
Georg Thieme Verlag KG Stuttgart · New York

Zervikale Rückenmarkverletzungen bei vorbestehender Spinalkanalstenose

Cervical Injuries to the Spinal Cord with Prior Stenosis of the Spinal Canal
Chris Schulz
,
René Mathieu
,
Uwe Max Mauer
Further Information

Publication History

Publication Date:
10 August 2018 (online)

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Zusammenfassung

Das Risikopotenzial eines Patienten mit asymptomatischer zSKS eine zRMV zu erleiden, ist nicht relevant erhöht. Gemessen an der perioperativen Morbidität und Mortalität zervikaler Dekompressions- und Fusionseingriffe sind prophylaktische Operationen für diese Subgruppe nicht zu empfehlen. Bei symptomatischen, insbesondere myelopathischen Patienten mit zSKS steigt einerseits die Sturzgefahr (als Folge der ataktischen Gangstörung), und die Prognose eines zRMV mit zSKS ist erwiesenermaßen schlechter als ohne additive zSKS. Somit sollten symptomatische Patienten mit zSKS insbesondere bei Versagen konservativer Maßnahmen und Progredienz der neurologischen Störungen oder auffälligen elektrophysiologischen Befunden eher einer elektiven Dekompression zugeführt werden. Bei milder zRMV (ASIA >D) kann zunächst ein konservativer Therapieversuch unternommen werden. Bei symptomatischer zRMV (ASIA C oder schlechter) und zusätzlicher zSKS geht der Trend eher hin zu dekomprimierenden Operationen, wenn in der Akut- oder frühen Frühphase nicht eindeutig eine rasche Besserung unter konservativer Therapie ersichtlich ist. Die aktuelle systematisch aufgearbeitete Studienlage zur zRMV favorisiert eine frühe OP (innerhalb von 24 h, bei zRMV mit inkompletter Neurologie sogar < 8 – 12 h). Ob dies auch für die Subgruppe von zRMV mit zSKS gilt, kann mit hochwertigen Studien und eindeutiger Evidenz noch nicht belegt werden. Für eine zervikale Dekompressionsoperation mit Duraerweiterungsplastik finden sich derzeit noch nicht genügend positive Hinweise. Zervikale Myelonverletzungen mit zSKS ziehen sehr häufig Begutachtungen nach sich. In Erwartung dessen sollten Anstrengungen unternommen werden, die initialen Befunde und den Verlauf sowie die durchgeführten Therapien möglichst lückenlos zu dokumentieren.

Abstract

Patients with asymptomatic cervical spinal stenosis do not exhibit a clinically relevant increase in the risk of cervical spinal cord injury. Prophylactic operations are not recommended for this subgroup, on account of the perioperative morbidity and mortality of cervical decompression and fusion surgery. In symptomatic patients, especially myelopathic patients with cervical spinal stenosis, the risk of falling increases (as a result of an ataxic gait) and the prognosis of a cervical spinal cord injury with cervical spinal stenosis is proven to be worse than without cervical spinal stenosis. For this reason, patients with symptomatic cervical spinal stenosis should generally be treated with elective decompression if conservative measures fail and neurological disorders worsen or electrophysiological findings are abnormal. Patients with a minor cervical spinal cord injury (ASIA Impairment Scale grade D or above) can initially receive conservative care. For symptomatic patients with a cervical spinal cord injury (ASIA Impairment Scale grade C or below) and additional cervical spinal stenosis, there is a general trend towards decompression operations if conservative treatment does not clearly result in rapid improvement during the acute or early phase. A systematic review of the current literature on cervical spinal cord injury suggests that early surgical intervention is favourable (within 24 hours; within 8 to 12 hours for cervical spinal cord injury with incomplete neurology). Whether this applies to the subgroup of cervical spinal cord injury with cervical spinal stenosis has not been proven in high quality studies and with unambiguous evidence. There are at present insufficient positive indications for cervical decompression surgery with dura enlargement. The treatment of cervical spinal cord injuries with cervical spinal stenosis often involves expert opinions. For this reason, efforts should be made to thoroughly document initial findings, the clinical course, and the treatment provided.

Schlüsselwörter

Halswirbelsäule - Rückenmark - Halswirbelsäulenverletzung - Halsrückenmarkverletzung - Halsrückenmarkstenose - Zervikalmyelopathie

Key words

cervical spine - spinal cord - cervical spine injury - cervical spinal cord injury - cervical spinal canal stenosis - cervical myelopathy
 

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