Die konservative und operative Therapie der unspezifischen Spondylodiszitis

Zusammenfassung

Die pyogene Spondylodiszitis entsteht meist endogen durch eine Bakteriämie, aber auch exogene Ursachen wie etwa wirbelsäulennahe Infiltrationen können sie hervorrufen. Es besteht eine zunehmende Inzidenz der Erkrankung, die noch immer mit einer signifikanten Mortalität der in vielen Fällen immunsupprimierten und hochbetagten Patienten einhergeht. Eine frühzeitige Diagnosestellung durch Bildgebung und Erregerisolierung ist entscheidend für ein gutes Behandlungsergebnis. Die überwiegende Zahl der Patienten kann konservativ behandelt werden, wichtig sind ein frühzeitiger Beginn der antibiotischen Therapie sowie eine adäquate Ruhigstellung. Operative Therapieziele sind neben der Dekompression und Infektsanierung die Stabilisation und Deformitätenkorrektur. Es kommen rein dorsale offene Verfahren, ggf. mit Ausräumung der Bandscheibe und TLIF, sowie minimalinvasive Stabilisierungen zur Anwendung. Bei ausgeprägten ventralen Destruktionen, Fehlstellungen und Abszedierungen muss durch einen separaten ventralen Zugang debridiert und stabilisiert werden. In der überwiegenden Zahl der Fälle können gute Behandlungsergebnisse erreicht werden, in Einzelfällen bestehen jedoch große therapeutische Herausforderungen. Individuelle Therapieentscheidungen sind notwendig, da einerseits die Literatur keine eindeutigen Behandlungsleitlinien vorgibt und es sich andererseits um teils hochbetagte und multimorbide Patienten handelt.

Abstract

Bacterial spondylodiscitis is mostly caused by endogeneous bacteremia, but also by direct external inoculation like perispinal infiltrations. There is an increasing incidence of this disease, which is still associated with a high mortality rate especially in the group of advanced aged or immunosuppressed patients. An early diagnosis by imaging and microbiology is essential for a good clinical outcome. The majority of patients can be treated conservatively, early antibiotic treatment and adequate immobilisation are important. Besides decompression and debridement, the goals of surgical therapy are stabilisation and deformity correction. Single standard posterior approaches, eventually with disc resection and TLIF/PLIF, as well as minimal invasive percutaneous stabilisation are being performed. In cases of severe anterior defects, deformities or abscesses, a separate anterior approach needs to be performed for debridement and stabilisation. In the majority of cases, a good outcome can be achieved, nevertheless single cases can be a therapeutic challenge. Individual therapeutical decisions are necessary since on the one hand the literature does not give explicit guidelines, and on the other hand high aged and multimorbid patients are being treated.

Schlüsselwörter

Spondylodiszitis - Antibiotika - konservative Therapie - operative Therapie

Keywords

spondylodiscitis - antibiotics - conservative therapy - surgical therapy

• Literatur

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