Minimalinvasive Therapie der Tumoren und Metastasen der Wirbelsäule durch Plasmafeldtherapie (Cavity Coblation) und Vertebro-/Kyphoplastie mit und ohne zusätzliche dorsale perkutane Instrumentation

Zusammenfassung

Hintergrund/Problemstellung/Fragestellung: Die Durchführung einer großen Operation bei Tumoren/Metastasen der Wirbelsäule ist in vielen Fällen unmöglich, vor allem bei älteren, multimorbiden Patienten mit höheren OP-Risiken. Behandlungsziele: Minimalinvasiv, aber maximal effektiv, Schmerzreduktion, Tumorentfernung, Reduktion der Fraktur- und Deformationsgefahr, Verbesserung der Lebensqualität. Die moderne Methode der perkutanen Cavity Coblation wird bei uns seit über 5,5 Jahren erfolgreich eingesetzt. Ziel dieser Arbeit/Fragestellung: Die Besonderheiten der Methodik, Problematik, OP-Technik, Ergebnisse der Behandlung von über 218 Patienten mit Wirbelkörpertumoren/Metastasen zu ermitteln und zu präsentieren. Patienten/Material und Methodik: Männliche und weibliche Patienten jeden Alters mit Metastasen/Osteolysen bzw. Frakturen an der Wirbelsäule. Diagnosesicherung durch klinische und radiologische Untersuchungen. Follow-up in regelmäßigen Abständen. Mithilfe der Cavity-SpineWand-Sonde (Fa. ArthroCare) wird durch die sog. Coblation (= kontrollierte Ablation auf der Basis plasmavermittelter Hochfrequenzenergie) eine Höhlung im Tumor erzeugt bzw. eine Tumorresektion bewirkt, zusätzlich erfolgt eine Wirbelstabilisierung durch Kypho-/Vertebroplastie. Zugang: perkutan trans-/extrapedikulär. Durch die Beseitigung von Tumorgewebe erreicht man Folgendes: Platz zur Zementauffüllung ohne Druck, fast komplette Zerstörung von Tumorzellen, Rezidivrisiko, Frakturgefährdung und Kompression der neuralen Strukturen werden deutlich reduziert [1], [2]. Ergebnisse: Innerhalb von 5,5 Jahren (03/08–09/13) wurden 218 Patienten (144 w., 74 m., Alter 31–92 J.) mit Wirbeltumoren (symptomatische große Hämangiome) und -metastasen mit dieser Methode behandelt. In 59 Fällen wurde zusätzlich eine dorsale perkutane Instrumentation und Aufrichtung durchgeführt. Die Ergebnisse wurden klinisch und radiologisch 2 und 14 Tage bzw. 3, 6, 12, 24, 36, 48 und 60 Monate postoperativ kontrolliert (noch nicht bei allen Patienten), und zwar auf folgende Parameter: Schmerzen, neurologische Defizite, Stabilität, Lokalrezidiv, Materiallockerung, Zufriedenheit. Es zeigten sich: Deutliche Schmerzreduktion, Zufriedenheit und Lebensqualitätsverbesserung sofort und im Verlauf bei allen Patienten. Außerdem schnelle Mobilisation nach OP, minimaler Blutverlust, sofortige Radiatio und Chemotherapie. Die Kombination der Cavity-Coblation-Methode mit Chemotherapie und Radiatio minderte deutlich die Rezidivrate. Komplikationen: in 29 Fällen geringe Zementaustritte nach ventral, lateral bzw. in das BS-Fach, ohne klinischer Relevanz, ohne Verletzung der Organe, Gefäße und Nerven. 65 Patienten (43 Frauen, 22 Männer) sind inzwischen wegen Tumormanifestation bei der Metastasierung in die inneren Organe verstorben. Schlussfolgerung: Die Cavity-Coblation-Methode zur Behandlung der Tumoren/Metastasen der Wirbelsäule stellt ein sicheres minimalinvasives Verfahren dar, was durch kurz- und langfristige Ergebnisse belegt wurde. OP-Risiken, v. a. Blutverlust und OP-Zeiten, werden deutlich geringer und kürzer. Die Methode ist aus unserer Sicht für die Zukunft vielversprechend.

Abstract

Background: Realisation of a major operation of tumours/metastases in the backbone is in many cases not possible, above all in older multimorbid patients with higher OP risks. So it is important to proceed here so minimally invasive as possible, but at least actually to reduce above all pain for the patient and the danger of other fractures and deformations and to improve thereby the quality of life. The modern method of the percutaneous cavity coblation by plasma field has been known for a short time and has been used by us for 5.5 years successfully. The aim of this work is to present the specific features of the methodology, problems, OP technology, results of the treatment of more than 218 patients with spine tumours/metastases. Patients/Material and Methods: Old and young patients with spinal tumours (painful large haemangiomas) and metastases were treated. The Cavity SpineWand device (ArthroCare) provides a space in the tumour by patented coblation technology (coblation = controlled ablation, based on plasma-provided high-frequency energy) and can be used with additional procedures such as, for example, cement injection for vertebral stabilisation – kypho-/vertebroplasty. Access to the backbone occurs percutaneously and transpedicularly, in some cases extrapedicularly. By the removal of tumour tissue not only space for the cement replenishment is achieved, but also complete destruction/vaporisation of the tumour cells. Recurrence risk, fracture danger and compression of the neural structures are clearly reduced thereby. Results: Within the 5.5 years (03/2008–09/2013) we treated 218 patients (144 f., 74 m., age 31–92 years) with spinal tumours and backbone metastases with this method. In 59 cases it was carried out in addition to dorsal percutaneous instrumentation and erection. Results of clinical and radiological evaluations were assessed at 2 and 14 days as well as at 3, 6, 12, 24, 36, 48 and 60 months post-surgery (but not for control with all patients on account of the shorter method application time). A clear pain reduction and with it satisfaction and quality of life improvement were seen for all patients. In several cases treatment was combined with chemotherapy or radiotherapy by which also tumour cell growth or recurrence could be clearly diminished. Patients could be mobilised quickly after surgery, blood loss was minimal, further oncological treatment could be initiated immediately. Especially for haemangiomas in one or several levels with massive bleeding tendency and danger of cement embolism, these risk factors were clearly minimised by ablation and coagulating the tumour vessels. Complications: in 29 cases with especially large osteolytic defects slight cement escape was observed paravertebrally (forwards, lateral and in the intervertebral disc field), without clinical relevance, an intervention was not necessary. 65 patients (43 f., 22 m.) died due to tumour intoxication. Conclusion: The percutaneous cavity coblation method for the treatment of tumours and metastases in the spine represents a sure, minimally invasive procedure for patients as demonstrated by short-term and long-term results. Due to the percutaneous, minimally invasive access, the OP risks, especially blood loss and OP times are clearly low and shorter. This new method is as yet only available in a few medical centres in Germany as well as in other countries but at the moment it is being used successfully and from our point of view has a promising future.

Schlüsselwörter

Cavity Coblation - Tumoren und Metastasen an der Wirbelsäule - Frakturen und Osteolysen - Multimorbidität

Key words

cavity - coblation - spine tumours and metastases - fracture and osteolysis - multimorbidity

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