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Die Wirbelsäule 2017; 01(02): 101-116
DOI: 10.1055/s-0043-105504
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Degenerative Lumbale Instabilität – Definition, klinische und radiologische Zeichen, Management

Degenerative Lumbar Instability – Definition, Clinical and Radiological Signs, Management
Yu-Mi Ryang
Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München
,
Haiko Pape
Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München
,
Bernhard Meyer
Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
03. Mai 2017 (online)

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Zusammenfassung

Hintergrund Im klinischen Alltag von Wirbelsäulenchirurgen stellen Patienten mit Rücken- und oder Beinschmerzen aufgrund degenerativer LWS-Prozesse einen Großteil des zu behandelnden Patientenguts dar. Trotz der Häufigkeit dieses Erkrankungsbildes gestaltet sich die Diagnosestellung dennoch oft schwierig, da klinische Symptome und bildgebende Befunde meist unspezifisch sind. Somit stellt uns die Therapie dieser Volkskrankheit immer wieder vor große Herausforderungen, da das optimale Ziel, nämlich das Erreichen eines anhaltend guten oder zumindest zufriedenstellenden Therapieerfolgs häufig ausbleibt, unabhängig von der gewählten Therapieform.

Wünschenswert wären prognostische Tests, die ein positives Ansprechen auf eine Therapieform (konservativ vs. operativ) voraussagen könnten. Eine der umstrittensten Erkrankungen aus dem degenerativen Formenkreis stellt die degenerative Instabilität und Mikroinstabilität dar. Auf die Frage, die uns als Wirbelsäulenchirurgen besonders interessiert, nämlich welche dieser Patienten von einer Operation, insbesondere einer spinalen Fusion, profitieren würden, gibt es leider immer noch keine klare Antwort.

In diesem Übersichtsartikel werden die klinischen und radiologischen Untersuchungsmethoden und auch konservative und operative Therapieoptionen dargestellt unter Berücksichtigung der aktuellen Literatur.

Methoden Literaturrecherche und Übersicht über das Thema degenerative Instabilität.

Zusammenfassung Die degenerative Instabilität bleibt ein schwieriges und kontroverses Thema. Sichere klinische und radiologische Zeichen wie auch valide prognostische Tests, um ein positives Outcome nach spinaler Fusion vorherzusagen, fehlen bisher leider ebenso wie ein Behandlungsalgorithmus zur Therapie der sogenannten Mikroinstabilität.

Bei der degenerativen Pseudolisthesis scheinen Patienten von einer stabilisierenden Operation im Vergleich zur alleinigen Dekompression hinsichtlich des Outcomes zu profitieren, hier werden eventuell die Langzeitergebnisse aus den 2016 im New England Journal of Medicine erschienenen RCTs Klarheit bringen.

Abstract

Background In the daily clinical practice of spine surgeons patients with low back pain and/or neurogenic leg pain due to degenerative diseases of the lumbar spine pose the majority of patients. Despite the high incidence of this disease it is still difficult to correctly diagnose the underlying pathology since clinical and radiological signs are mostly unspecific. Therefore, therapy of this widespread disease poses a special challenge since good or satisfactory longterm outcomes are rare, independent of the chosen management.

It would be desirable to have prognostic tools to predict a positive outcome after treatment (nonsurgical vs. surgical). One of the most controversial topics are degenerative instability and microinstability. Concerning the question, which we as spine surgeons find especially interesting, namely, which of these patients would benefit from surgery, especially spinal fusion, there is still no clear answer. In this review article clinical and radiological examination methods as well as methods of nonsurgical and surgical manangement are illustrated in detail with special focus on the recent literature.

Methods Literature search und overview on the topic of degenerative instability.

Conclusion The topic degenerative instability remains controversial. Reliable clinical and radiological signs as well as prognostic tests to predict a positive postoperative outcome are still lacking, as is a treatment algorithm for microinstability.

In cases of degenerative pseudolisthesis, there are data suggesting an advantage of spinal fusion over decompression alone. Longterm results from the NEJM RCTs from 2016 will hopefully clarify this in the future.

Schlüsselwörter

degenerative lumbale Instabilität - Mikroinstabilität - Degenerative Spondylolisthese - Pseudolisthese - Olisthese - Operative Therapie

Key Words

degenerative lumbar instability - microinstability - degenerative spondylolisthesis - pseudolisthesis - olisthesis - surgical therapy
 

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