Die Veränderung des sagittalen Profils im Alter und dessen therapeutische Relevanz

Zusammenfassung

Die steigende Zahl der komplexen Wirbelsäulendeformitäten im Alter stellt eine neue therapeutische Herausforderung dar. Hierbei wird dem komplexen Zusammenspiel der spinopelvinen Kompensationsmechanismen eine besondere Bedeutung zugeschrieben. Obwohl die Analyse der globalen sagittalen Balance wesentlich zum Verständnis dieser Mechanismen beigetragen hat, wird die vereinfachte algebraische Darstellung und Definition des „normalen“ Sagittalprofils dem älteren Patienten mit multiplen degenerativen Veränderungen des Bewegungsapparates nicht gerecht. Vielmehr ist beim älteren Patienten eine durch die unzureichende Flexibilität der benachbarten Strukturen limitierte „Komfort-Balance“ funktionell nicht zwingend nachteilig. Dennoch sollte das therapeutische Ziel immer die Wiederherstellung einer harmonischen Lastverteilung an der Wirbelsäule sein. Bei älteren Patienten mit einer symptomatisch dekompensierten sagittalen Imbalance, bleibt die rein konservative Therapie meist ohne Erfolg. In diesen Fällen sollte immer die strukturell zugrunde liegende Pathologie im Sinne der Profilkorrektur adressiert werden. Die Wahl der operativen Technik, Länge des Konstrukts und dessen Verankerungspunkte müssen dabei die individuellen Möglichkeiten, Risiken und Bedürfnisse des älteren Patienten berücksichtigen, um eine iatrogene Invalidisierung und komplikationsbedingte Sekundäreingriffe zu vermeiden. Mit stetig steigender Lebenserwartung unserer Bevölkerung werden wir uns dem wachsenden Anspruch, auch im hohen Alter aktiv bleiben zu können, stellen müssen. Dies setzt ein ganzheitliches Verständnis der patienteneigenen Leistungsfähigkeit sowie eine realistische Einschätzung des zu erzielenden Ergebnisses und das Beherrschen aller operativer Korrekturtechniken voraus.

Abstract

The increasing number of complex spinal deformities in the ageing population poses a new therapeutic challenge to spinal care worldwide. Among the key influencing factors are the complex interactions of all spinopelvic compensatory mechnisms. In the past two decades, the analyses of the global sagittal balance has cleary enhanced our understanding of these mechanisms. However, in the ageing patient, the common algebraic approach and definition of a „normal“ sagittal balance may be oversimplified and not appropriate. Therefore, a certain degree of „comfort balance“, limited by the insufficient flexibility of neighboring (degenerated) structures, does not necessarily have a negative impact on the functional outcome. The primary therapeutic goal, however, should always be the restoration of the harmonic spinal load distribution. While conservative therapy mostly is a justifiabe primary therapeutic approach in the ageing patient, a symptomatic decompensated sagittal imbalance seldomly shows a beneficial response. In such cases, the underlying pathologic structure should be addressed surgically in terms of correcting the global spinal profile. The choice of approach, surgical technique, length of construct and its anchoring points should always respect the individual requirements, risks and expectations of the ageing patient. By observing these critical parameters, we may be able to reduce the risk of iatrogenic disablement or repeated interventions due to complications. With the increase of an ageing population and, in equal measure, the increase of the overall demand to retain an active life, we must face these challenges with respect and self-critique. This implies a thorough understanding of the patient-specific capabilities, a realistic evaluation of the achievable results and the mastering of all surgical techniques.

Schlüsselwörter

Sagittale Balance - Wirbelsäulendeformitäten - Korrekturtechniken

Key words

sagittal balance - spinal deformity - correction techniques

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