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DOI: 10.1055/a-0841-3848
Anular Closure RCT – Interpretation der Ergebnisse und Bedeutung für die klinische Entscheidungsfindung im Jahr 2019
Anular Closure RCT – Interpretation of results and impact for clinical decision-making in 2019Publication History
Publication Date:
17 April 2019 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00033104/201902/lookinside/thumbnails/8413848_10-1055-a-0841-3848-1.jpg)
Zusammenfassung
Obwohl die lumbale Bandscheibenoperation als häufigster wirbelsäulenchirurgischer Eingriff mit sehr guten klinischen Ergebnissen in Verbindung gebracht wird, besteht ein relevantes Reherniations- und Reoperationsrisiko. Dies gilt insbesondere für Patienten mit hohen Bandscheiben und großen Anulusdefekten, also für bis zu 30 % des Gesamtkollektivs. Um die Rezidivraten nach Mikrodiskektomie zu senken, wurde ein Anulusverschlussimplantat (ACD) entwickelt und kürzlich in einem großen Multicenter-RCT evaluiert. Dieser Übersichtsartikel soll die publizierten Daten und deren Bedeutung für die wirbelsäulenchirurgische Praxis zusammenfassen.
In der Kontrollgruppe des RCT konnte die hohe Rezidivrate von ca. 25 % für diese Hochrisikopopulation nach limitierte Mikrodiskektomie bestätigt werden. Die Reherniationsrate wurde durch das Implantat um die Hälfte gesenkt, so dass bei einer Häufigkeit von Implantat-bedingten Revisionen von unter 3 % auch eine Halbierung der Reoperationsrate erzielt wurde. Die nach harten Kriterien definierte Erfolgsquote betrug ohne Implantat 66 % und mit ACD 76 %. Diese statistisch signifikanten Unterschiede in Reoperations- und Erfolgsraten führten nach 3 Jahren auch zu einem signifikanten Outcomevorteil. Auffällig waren häufige Endplattenveränderungen bei ACD-Patienten, die zwar ohne klinische Konsequenzen blieben, aber eine Langzeitbeobachtung anraten.
Bei der Hochrisikopopulation macht ein Anulusverschluss nach aktueller Datenlage Sinn und verbessert das Operationsergebnis, so dass der Patientenselektion entscheidender Stellenwert zukommt.
Abstract
Although lumbar microdiscectomy as the most common spinal procedure worldwide is considered a largely successful procedure, it carries a significant risk of reherniation, consecutive reoperation and unsatisfactory outcome. Patients with high discs and large anular defects have been identified to be particularly prone for recurrence. In an attempt to reduce rehernation rates an anular closure device has been developed and recently tested in a large multicenter RCT. This paper aims at reviewing the corresponding published data and its impact on spine surgery practice.
The control group in the RCT confirmed the high recurrence rate of 25 % after limited microdiscectomy in this high-risk subpopulation. The implant reduced reherniation and reoperation rates by half, as implant-associated revisions were rare (< 3 %). The strictly defined success rate amounted to 66 % vs. 76 % in favor of the ACD. These statistically significant differences resulted in a significant outcome difference after 3 years. Endplate lesions were very common in ACD patients, but not related to clinical outcome. This finding nevertheless warrants long-term follow-up.
In summary, anular closure improves outcome in the high-risk subpopulation and thus makes sense, but patient selection is crucial.
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