Sagittales Profil der Wirbelsäule: Was ist sinnvoll, was gefährdet den Patienten, was ist Hype? Kontra: Patienten- und morbiditätsadjustiertes Vorgehen

Zusammenfassung

Hintergrund Der Zusammenhang zwischen der globalen sagittalen Balance und dem klinischen Outcome bei adulter spinaler Deformität hat in den letzten 30 Jahren sehr stark an Bedeutung zugenommen. Allerdings ist die Evidenzlage mit diesem Hype nicht mitgewachsen.

Ziele der Arbeit In dieser Arbeit wird die Evidenzlage kritisch diskutiert und ein abgestuftes Behandlungsvorgehen vorgestellt.

Material und Methoden Es erfolgte eine ausführliche Literaturrecherche über Medline sowie die Zusammenfassung der Meinung der Autoren.

Ergebnisse Bis auf wenige systematische Reviews haben alle publizierten Arbeiten Evidenzlevel III oder IV. Die absolute Mehrheit dieser Veröffentlichungen berichten über Korrelationen zwischen radiologischen Parametern der spinopelvinen Balance und dem klinischen Befinden des Patienten. Eine prospektive randomisierte Studie über die Effektivität der Wiederherstellung der sagittalen Balance gibt es nicht. Erschwerend hinzu werden die sehr hohe Komplikations- und Reoperationsraten nach Operationen zu Wiederherstellung der sagittalen Balance beobachtet.

Diskussion Solange keine eindeutige Evidenz besteht, muss die Indikation zur Korrekturoperation extrem zurückhaltend gestellt werden. Wenn diese Form der Chirurgie überleben will, muss sie sich den Kriterien einer evidenzbasierten Evaluation unterziehen.

Abstract

Background The relationship between global sagittal balance and clinical outcome in adult spinal deformity has gained much popularity over the last 30 years. However, the medical evidence to support this hype has not grown accordantly.

Aims of the study We discuss the evidence in the literature so far and propose a staged treatment approach for patients with adult spinal deformity.

Material and methods A detailed literature search on Medline and a summary of author’s opinion.

Results Except for a few systematic reviews, all published papers have evidence levels III or IV. The absolute majority of these publications report correlations between radiological parameters of spinopelvic balance and the clinical condition of the patient. A prospective randomised trial evaluating the efficacy of sagittal balance restoration does not exist. Moreover, surgical procedures aiming to restore the sagittal balance are associated with very high complication and revision rate.

Discussion As long as there is no clear evidence, the indication for surgery to restore sagittal balance must not be made easily. If this form of surgery is to survive, it must undergo the criteria of evidence-based evaluation.

Schlüsselwörter

sagittales Profil - Korrektur - Evidenz - Komplikationen

Keywords

sagittal profile - correction - evidence - complications

• Literatur

• 1 Smith JS, Klineberg E, Lafage V. et al. International Spine Study Group. Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery. J Neurosurg Spine 2016; 25: 1-14
• 2 Smith JS, Shaffrey CI, Klineberg E. on behalf of the International Spine Study Group et al. Complication rates associated with 3-column osteotomy in 82 adult spinal deformity patients: retrospective review of a prospectively collected multicenter consecutive series with 2-year follow-up. J Neurosurg Spine 2017; 27: 444-457
• 3 Le Huec JC, Faundez A, Dominguez D. et al. Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review. Int Orthop 2015; 39: 87-95
• 4 Glassman SD, Bridwell K, Dimar JR. et al. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 2005; 30: 2024-2029
• 5 Terran J, Schwab F, Shaffrey CI. et al. The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery 2013; 73: 559-568
• 6 Schwab FJ, Hawkinson N, Lafage V. et al. International Spine Study G. Risk factors for major peri-operative complications in adult spinal deformity surgery: a multi-center review of 953 consecutive patients. Eur Spine J 2012; 21: 2603-2610
• 7 Scheer JK, Smith JS, Clark AJ. et al. International Spine Study Group. Comprehensive study of back and leg pain improvements after adult spinal deformity surgery: analysis of 421 patients with 2-year follow-up and of the impact of the surgery on treatment satisfaction. J Neurosurg Spine 2015; 22: 540-553
• 8 Hyun SJ, Rhim SC. Clinical outcomes and complications after pedicle subtraction osteotomy for fixed sagittal imbalance patients: a long-term follow-up data. J Korean Neurosurg Soc 2010; 47: 95-101
• 9 Liu S, Schwab F, Smith JS. et al. Likelihood of reaching minimal clinically important difference in adult spinal deformity: a comparison of operative and nonoperative treatment. Ochsner J 2014; 14: 67-77
• 10 Smith JS, Klineberg E, Schwab F. et al. Change in classification grade by the SRS-Schwab Adult Spinal Deformity Classification predicts impact on health-related quality of life measures: prospective analysis of operative and nonoperative treatment. Spine (Phila Pa 1976) 2013; 38: 1663-1671
• 11 Smith JS, Shaffrey CI, Berven S. et al. Operative versus nonoperative treatment of leg pain in adults with scoliosis: a retrospective review of a prospective multicenter database with two-year follow-up. Spine (Phila Pa 1976) 2009; 34: 1693-1698
• 12 Shin EK, Kim CH, Chung CK. Sagittal imbalance in patients with lumbar spinal stenosis and outcomes after simple decompression surgery. Spine J 2017; 17: 175-182
• 13 Bayerl SH, Pöhlmann F, Finger T. et al. The Sagittal Balance Does not Influence the 1 Year Clinical Outcome of Patients With Lumbar Spinal Stenosis Without Obvious Instability After Microsurgical Decompression. Spine (Phila Pa 1976) 2015; 40: 1014-1021
• 14 Yilgor C, Sogunmez N, Boissiere L. et al. European Spine Study Group (ESSG). Global Alignment and Proportion (GAP) Score: Development and Validation of a New Method of Analyzing Spinopelvic Alignment to Predict Mechanical Complications After Adult Spinal Deformity Surgery. J Bone Joint Surg Am 2017; 99: 1661-1672
• 15 Schwab F, Ungar B, Blondel B. et al. Scoliosis Research Society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976) 2012; 37: 1077-1082