Osteoporotische Wirbelkörperfraktur

Zusammenfassung

Die Osteoporose ist ein zunehmendes Problem der muskuloskeletalen Medizin. Neben einer zunehmenden Inzidenz im Alter ist ein weiteres epidemiologisches Phänomen zu beobachten. Aktuell werden im höheren Alter zunehmend komplexere Verletzungsmuster beschrieben. Eine Osteoporose kann also zum einen zu Spontanfrakturen (Sinterung) führen, zum anderen als koinzidenteller Faktor von Bagatelltraumen wie auch von „echten“ traumatischen (hochenergetischen) Verletzungen auftreten. Die diagnostischen Möglichkeiten, zwischen diesen Entitäten zu unterscheiden, stellen den Behandler hierbei vor eine gewisse Herausforderung. Eine valide Klassifikation, die den Besonderheiten der Verletzungen der osteoporotischen Wirbelsäule Rechnung trägt, ist leider noch nicht etabliert. Die prinzipiellen Behandlungsziele und -prinzipien unterscheiden sich bei den Wirbelkörperfrakturen bei Osteoporose nicht wesentlich von den sonstigen Prinzipien beim Knochengesunden. Dennoch bietet die osteoporotische Wirbelsäule besondere Herausforderungen. Hierbei besteht die Möglichkeit, den Wirbelkörper selbst zu stabilisieren. Dies erfolgt oft kombiniert mit einer intravertebralen Aufrichtung und dem Einfüllen von PMMA oder alternativen Substanzen. Weiter kann mittels Pedikelschrauben das Bewegungssegment stabilisiert werden. Der Halt der Schrauben im Wirbelkörper kann hierbei ebenfalls mit PMMA verbessert werden. Eine ventrale Abstützung kann entweder durch einen weiteren ventralen Eingriff oder über eine Kombination von augmentierenden Verfahren des frakturierten Wirbelkörpers mit der dorsalen Instrumentierung erreicht werden. Diese mannigfaltigen therapeutischen Möglichkeiten erfordern ein differenziertes Vorgehen. Letztlich darf bei jeglicher chirurgischen Therapie die Behandlung der Grunderkrankung Osteoporose nicht vergessen werden.

Abstract

Osteoporosis is an increasing problem in musculoskeletal medicine. In addition to the increasing incidence of osteoporosis in the elderly, another epidemiological phenomenon has been observed. Increasingly complex injury patterns are currently being reported in elderly people. Osteoporosis can lead to spontaneous fractures (sintering), but may coincide with trivial trauma, as well as with „real“ traumatic (high-energy) injuries. The diagnostic possibilities to distinguish between these entities can a challenge for the practitioner. A valid classification, which takes account of the special features of the injuries of the osteoporotic spine, is unfortunately not yet established. The basic treatment objectives and principles for the vertebral body fractures in osteoporosis should not differ significantly from those principles of applicable to patients without osteoporosis. However, the osteoporotic spine offers special challenges. One possibility is to stabilise the vertebral body itself. This is often combined with restauration of the vertebral body and filling it with PMMA or alternative substances. Furthermore, the motion segment can be stabilised by means of pedicle screws. Anchorage of the screws in the osteoporotic vertebral body can also be improved by PMMA. Anterior support may be achieved, either by additional ventral intervention or by posterior combination of augmented treatment of the fractured vertebral body with dorsal instrumentation. These diverse therapeutic possibilities require a differentiated approach to treat the variety of different injuries in osteoporotic spines. Ultimately, the treatment of the underlying osteoporosis must not be forgotten in any surgical treatment.

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