Treatment of Cervical Degenerative Disc Disease – Current Status and Trends

Abstract

Although less frequent than lumbar degenerative disc disease, cervical disc disease may be much more neurologically compromising due to anatomical particularities. Since its first description together with the typical signs and symptoms the operative therapy of cervical disc disease has undergone a changeful evolution over the years. The frequent shifts of paradigms in treatment are particularly noticeable compared to other neurosurgical diseases. Initially, the dorsal decompression of neural structures (laminectomy) with a more or less invasive posterior approach (posterior foraminotomy) was the primary aim of the operation. Because of anatomical limitations, a paradigm shift occurred in the middle of the last century, favouring an anterior approach and discectomy, without and with implantation of various spacers (arthrodesis). A large variety of different materials and designs for these implants as alternatives to autologous iliac crest bone were established, all with the aim of creating a solid fusion of the operated segment. Anterior cervical discectomy and fusion (ACDF), regarded worldwide as the “gold standard” for the treatment of cervical disc disease, was later complemented by modified, minimally invasive or endoscopic techniques using anterior and posterior approaches. The fear of adjacent level disease in the vicinity of a fused cervical segment led to another paradigm shift in the last few years, away from fusing procedures, towards new motion preserving technologies (arthroplasty) and back to minimally invasive dorsal techniques for the treatment of cervical disc disease. This article reviews the evolution of the operative treatment of cervical disc disease in the last 80 years, outlines the advantages and disadvantages of each approach and technique and focuses on the rationale of the paradigm shifts. Current established and alternative treatment concepts are illuminated and discussed together with the currently relevant literature.

Zusammenfassung

Zervikale Bandscheibenvorfälle treten zwar seltener als lumbale degenerative Veränderungen auf, können jedoch auf Grund der anatomischen Besonderheiten neurologisch gefährdender sein. Seit der Erstbeschreibung des damit verbundenen Symptomkomplexes hat ihre operative Therapie eine abwechslungsreiche Evolution mit häufig wechselnden Behandlungsparadigmen, anders als andere neurochirurgische Krankheitsbilder, vollzogen. War zunächst die dorsale Dekompression neuraler Strukturen (Laminektomie) mit immer kleiner werdendem Zugang (posteriore Foraminotomie) das primäre Operationsziel, kam es in der Mitte des letzten Jahrhunderts, zumeist aus morphologisch-anatomischen Gründen, zu einem Paradigmenwechsel mit der Favorisierung von ventralen Zugängen und Diskektomien ohne und mit Implantation verschiedener Platzhalter (Arthrodese). Hier etablierten sich eine Vielzahl von Materialien und Designs als Alternative zum autologen Beckenkamminterponat mit dem zusätzlichen Ziel der soliden Fusion des operierten Segments. Die anteriore zervikale Diskektomie mit Fusion (ACDF) als international anerkannter “Goldstandard” wurde weiterhin durch modifizierte, minimal invasive oder endoskopische Techniken von ventral und von dorsal ergänzt. Unter anderem aus Furcht vor beschleunigtem Verschleiß in der Nachbarschaft der zu fusionierten Segmenten, kommt es in den letzten Jahren zu einem erneuten Paradigmenwechsel, weg von versteifenden, hin zu funktionserhaltenden neuen Techniken (Arthroplastie) und zurück zu minimal invasiven dorsalen Techniken, bei der Behandlung des zervikalen Bandscheibenvorfalls. Ziel dieser Arbeit ist die Darstellung der Entwicklung der operativen Behandlung des zervikalen Bandscheibenvorfalls über die letzten 80 Jahre mit den Vor- und Nachteilen der jeweiligen Zugänge und Techniken und der Fokussierung auf die rationalen Begründungen der Paradigmawechsel. Derzeitige etablierte und alternative Behandlungskonzepte werden zusammen mit Trends aufgezeigt und anhand der aktuellen Literatur relevanter Studien diskutiert.

Key words

cervical disc disease - anterior approach - posterior approach - fusion - motion preservation

Schlüsselwörter

zervikaler Bandscheibenvorfall - ventraler Zugang - dorsaler Zugang - Fusion - Bewegungserhalt

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