Original Article pissn eissn J Korean Soc Spine Surg Jun;19(2): Is It Nece

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Journal of Korean Society of Spine Surgery Is It Necessary to Add Anterior Decompression after Posterior Decompression for Thoracolumbar and Lumbar Fractures with Neurologic Deficit? Jae-Won You, M.D., Hong-Moon Sohn, M.

Sinheung-Dong, Jung-Gu, Incheon, 400-711, Korea Tel: 82-32-890-3044 Fax: 82-32-890-3467 Copyright 2011 Korean Society of Spine Surgery pissn 2093-4378 eissn 2093-4386 The online version of this

1 Journal of Korean Society of Spine Surgery Is It Necessary to Add Anterior Decompression after Posterior Decompression for Thoracolumbar and Lumbar Fractures with Neurologic Deficit? Jae-Won You, M.D., Hong-Moon Sohn, M.D., Sang-Soo Park, M.D. J Korean Soc Spine Surg 2012 Jun;19(2): Originally published online June 30, 2012; Korean Society of Spine Surgery Department of Orthopedic Surgery, Inha University School of Medicine #7-206, 3rd ST. Sinheung-Dong, Jung-Gu, Incheon, , Korea Tel: Fax: Copyright 2011 Korean Society of Spine Surgery pissn eissn The online version of this article, along with updated information and services, is located on the World Wide Web at: This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Original Article pissn eissn J Korean Soc Spine Surg Jun;19(2): Is It Necessary to Add Anterior Decompression after Posterior Decompression for Thoracolumbar and Lumbar Fractures with Neurologic Deficit? Jae-Won You, M.D., Hong-Moon Sohn, M.D., Sang-Soo Park, M.D. Department of Orthopaedic Surgery, School of Medicine, Chosun University, Gwangju, Korea Study Design: A retrospective study. Objectives: To understand the necessity of additional anterior decompression when treating with posterior decompression for thoracolumbar and lumbar fractures, with neurologic deficit. Summary of Literature Review: Additional anterior decompression is still a controversy after a posterior decompression Materials and Methods: We evaluated 38 patients who were treated with a decompression surgery for thoracolumbar and lumbar spine fractures with neurologic deficit. In the posterior decompression group, there were 26 patients, and there were 12 patients in the posterior and anterior decompression group. According to the Frankel grade, neurologic deficit was grade A 3, B 1, C 3, D 31, respectively. Unstable burst fractures were 22, flexion-distraction injuries 12, Chance fractures 2 and translational injuries 2 by the McAfee classification. Radiographic evaluation was carried out with comparison of the spinal canal encroachment and kyphotic angle. We evaluated the improvement of neurology, and compared with that of the preoperative canal encroachment. Results: During the posterior decompression, 5 neural injuries were found in the post. decompression group, and 4 in the post. and ant. decompression group. There was no significant difference of neurologic improvement between the two groups (improvement in 18(69%) and 8(67%), respectively) (p>0.05). Preoperative canal encroachment was 62% and 76%, respectively. But, preoperative canal encroachment and final neurologic improvement showed no significant correlations between the two groups (p>0.05). Conclusions: We could not find the difference of neurologic improvement between the post. decompression group and post. and ant. decompression group. We suggest that an additional ant. decompression for the thoracolumbar and lumbar spine fractures treated with post. decompression is not necessary. Key Words: Thoracolumbar fracture, Neurologic deficit, Posterior decompression, Anterior decompression 서론 흉요추부의불안정성골절은신경학적증상의호전, 변형교정및조기보행을위하여대부분수술적치료가필요하다. 1) 수술적방법으로는전방도달법에의한수술, 후방도달법에의한수술또는전방및후방도달법에의한수술이있는데골절의형태나신경학적결손유무등에따라수술방법이결정되며최적의치료방법에대해서는아직까지의견이분분하다. 신경학적인결손이있는경우에는병변을직접제거하고유합범위를줄일수있는장점이있는전방감압술및유합술이일반적으로선호되고있지만전방도달법은후방구조물이손상되어불안정성을야기하는경우는후방유합술을추가해야하는단점이있다. 후방도달법에의한감압술및유합술은척추외과의사들에게전방도달법보다더친숙한방법이며, 골절에대한해부학적정 Received: February 7, 2012 Revised: May 14, 2012 Accepted: June 4, 2012 Published Online: June 30, 2012 Corresponding author: Hong-Moon Sohn, M.D. Department of Orthopaedic Surgery, Chosun University Hospital, 588 Seosuk- Dong, Dong-Gu, Gwangju , Korea TEL: , FAX: hmsohn@chosun.ac.kr This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 이논문은 2009 년도조선대학교학술연구비의지원을받아연구되었음. Copyright 2012 Korean Society of Spine Surgery 31

Jae-Won You et al Volume 19 Number 2 June 2012 복및정렬이가능하고후방인대복합체의손상에서도이용할수있으며, 전위된골절편에의한신경압박이남아있는경우에는후방또는후외방감압술을추가하여직접압박된신경을감압시킬수있는유용한방법이다.

3 Jae-Won You et al Volume 19 Number 2 June 2012 복및정렬이가능하고후방인대복합체의손상에서도이용할수있으며, 전위된골절편에의한신경압박이남아있는경우에는후방또는후외방감압술을추가하여직접압박된신경을감압시킬수있는유용한방법이다. 또한최근흉요추방출성골절에서추궁판의부분골절이동반된경우 25% 의환자에서경막파열이관찰되었으며파열된경막을봉합해주지않으면심한외상성지주막염의가능성이있으므로이런경우후방감압술이전방감압술보다더유용하다고보고되었다. 2) Bradford 와 McBride 3) 는흉요추방출성골절에대한전방및후방수술후신경증상의호전에대한연구결과전방수술군이더나은신경학적증상의호전을보고하였으나 McAfee 등 4) 은신경학적인증상을동반한흉요추방출성골절에서후외방 감압술로전예에서신경학적증상의호전을보고하여전방감압술의필요성에의문을제시했다. 저자들은신경학적증상을동반한흉요추및요추골절에대해후방감압술및유합술을시행한군과전방감압술을추가로시행한군을대상으로신경학적증상의호전과방사선학적변화를비교하여신경회복을위해추가적인전방감압술이유용한가에대하여알아보고자하였다. 대상및방법 2003 년 1월부터 2009 년 12월까지흉요추및요추골절로수술적치료를받은환자들중수술전신경학적증상이있었던환 Fig. 1. A 55 year-old male patient with L2 flexion-distraction injury and Frankel grade C neurologic deficit. Preoperative X-ray, sagittal and axial CT image showed 70% canal compromise and MRI showed neural compression and L1-2 interspinous ligament rupture(a-d). After posterior decompression and fusion, X-ray showed fracture reduction(e) and CT sagittal and axial view showed 50% canal compromise(f,g). His neurologic deficit improved to Frankel grade D3 after 1 year follow up. 32

$A 48 year-old male patient with T12 and L3 burst fractures and Frankel grade D neurologic deficit.$

4 Journal of Korean Society of Spine Surgery Additional Anterior Decompression for Thoracolumbar and Lumbar Fractures Fig. 2. A 48 year-old male patient with T12 and L3 burst fractures and Frankel grade D neurologic deficit. After posterior decompression and fusion, CT axial and sagittal view showed 70% canal compromise on L3. Anterior decompression with half corpectomy and fusion with mesh cage was done 1week after posterior surgery. His neurologic deficit improved to Frankel grade E after 1 year follow up. Serial X-ray(A), sagittal CT images(b) and axial CT images(c) showed preoperative, after posterior decompression and fusion and anterior decompression. 33

5 Jae-Won You et al Volume 19 Number 2 June 2012 Table 1. Initial and final neurologic status in Frankel s grade in posterior decompression only group. Final grade Initial grade Total A B C D E A B 0 C D E 0 Total Table 2. Initial and final neurologic status in Frankel s grade in anterior and posterior decompression group. Final grade Initial grade Total A B C D E A 1 1 B 1 1 C 1 1 D E 0 Total 자는 45예이었고, 추시과정에서 1년이상관찰이가능하였던 38예를대상으로하였다. 남자가 25예, 여자가 13예이었으며, 수상당시나이는평균 42세 (20-65 세 ) 이었다. 수상원인은추락사고 24예, 교통사고 12예, 스포츠손상 2예이었다. 후방감압술과유합술만받은예는 26예, 후방감압술및유합술후추가적으로전방감압술및유합술을받은예는 12예이었다. 전예에서흉요추부단순방사선촬영과수술전전산화단층촬영을하여방사선학적계측을하고골절을분류하였으며, 손상부위는제 11흉추 2예, 제 12 흉추 12예, 제 1요추 16예, 제 2요추 5예, 제 3요추가 2예, 제 4요추가 1예이었다. 골절의분류는 McAfee 등의분류에따라불안정성방출성골절 22예, 굴곡신연손상 12예, Chance 골절 2예, 전이성손상 2예이었으며, 전예에서수상전, 후고용량스테로이드투여는없었다. 수술이지연돼수상후 5일째후방감압술및유합술을시행한 1예를제외하고는전예에서수상후 3일이내에양측성후궁절제술로후방감압술을한후척추경나사를이용한장분절고정을하거나척추경손상이없는경우에는골절된추체에도일측성나사못을삽입하는단분절고정을하였다 (Fig. 1). 수술후전산화단층촬영을하여골편의정복여부를확 인한후척추관함입률이 40% 이상이면서신경학적증상이호전되지않은환자들은후방감압술후 1주일에서 2주일사이에전방감압술및유합술을추가적으로시행하였다 (Fig. 2). 신경학적인평가는 Frankel grade 5) 를이용하였고, 방사선학적평가는흉요추단순방사선촬영에서골절의압박률과 Cobb 씨각을이용한후만각을측정하였으며, 전산화단층촬영에서척추관함입률은 ( 상, 하척추관의평균정중시상직경-골절부골절편의끝에서후궁까지의거리 / 상, 하척추관의평균정중시상직경 ) 의백분율로계산하였다. 통계처리는윈도우용 SPSS 17.0프로그램의 Mann-Whitney U검정을이용하여 p값이 0.05 이하일때의의있는것으로간주하였다. 결과 후방감압술시행시경막의파열과신경근손상이후방감압술군 5예에서, 전후방감압술군 4예에서확인되어미세현미경하에서나일론 7-0을이용한경막봉합술을시행하였다. 평균추시기간은 2.5년 (1-6.2 년 ) 이었다. 34

6 Journal of Korean Society of Spine Surgery Additional Anterior Decompression for Thoracolumbar and Lumbar Fractures Table 3. Comparison of neurologic improvement between two groups (p>0.05) 1. 신경학적변화 수술전신경학적증상은 Frankel grade A 가 3 예 (8%), B 가 1 예 (3%), C 가 3 예 (8%), D 가 31 예 (82%) 이었다. 최종추시때양 군모두에서신경학적증상이악화된예는없었으며호전 23 예 (66%), 무변화 12 예 (34%) 이었다 (Table 1,2). 각군간을비교하 면후방감압술군에서호전 18 예 (69%), 무변화 8 예 (31%) 이었으 며전후방감압술군에서호전 8 예 (67%), 무변화 4 예 (33%) 를보 여두군간에의의있는신경학적호전의차이는없었다 (p>0.05) (Table 3). 2. 방사선학적변화 수술전후만각은후방감압술군 21.3 도 (15-41 도 ), 전후방감 압술군 23.5 도 (17-45 도 ) 이었으며, 1 차수술직후각각 2.2 도 (0-6 도 ) 및 1.5 도 (-1-5 도 ) 로호전되었으며최종방사선소견상 각각 3.3 도 (0-8 도 ) 및 2.3 도 (0-6 도 ) 로유지되었다 (Table 4). 수 술전척추관함입률은후방감압술군 62%(40-82%) 이었고, 전 후방감압술군 67%(38-87%) 로전후방감압술군에서약간더 많았으나의미있는차이는없었다 (p>0.05). 최종추시상척추관 함입률은후방감압술군에서평균 32%(20-40%) 이었으며, 전 후방감압술군에서는전방감압으로인해척추관함입률을측정 할수없었다. 양군에서수술전척추관함입률과신경학적증 상의호전과는의의있는차이는없었다 (p>0.05). 3. 합병증 후방감압술군에서 2 예, 전후방감압술군 1 예에서내고정물 파손이발생하였으며양군모두에서감염등기타합병증은없 었다. Improved No change Aggravated Post. only 18(69%) 8(31%) 0(0%) Post.+Ant. 8(67%) 4(33%) 0(0%) Table 4. Changes of kyphotic angle( o ) Preop Impo * Last F/U Post. only 21.3(15-41) 2.2(0-6) 3.3(0-8) Post.+Ant. 23.5(17-45) 1.5(-1-5) 2.3(0-6) * Impo; immediate post-operative 고찰 척추골절후발생한신경학적결손은완전마비에서부터단일신경근손상까지다양하며흉추및요추골절후신경학적증상의발생률은 22-25% 정도로보고되고있다. 6,7) 신경학적증상을동반한흉추및요추골절에서수술의결과는 16.7% 에서 85% 까지다양한신경증상의회복이보고되고있는데, Bradford 와 McBride 3) 은전방감압술시 88%, 후방감압술시 64% 의호전을보고하면서신경회복을위해서는전방감압술이더우수하다고보고하였다. 그러나후방감압술은수술시간이짧고실혈이적으며신연기구를이용한간접감압이가능하고다발성척추골절에단일절개로수술할수있는장점이있으며신경학적호전의정도도전방감압술과비교하여차이가없다는보고가많다. 4,8) 또한경막손상에의한척추신경근포착이있는경우에는후방에서추궁절제술을시행하여신경을직접감압해주어야한다. 2) 후방감압술로충분히경막과신경근의압박을풀어준후에도수술후 CT 촬영상전위된골편이남아있는경우이차적인전방감압술이필요한지에대해서는척추외과의사들간에일치된의견이없다. 1) 일반적으로후방감압술의장점과수술의편리성으로후방도달법을선호하지만후방감압술후에도신경증상의회복이없으면술후 CT에서흉요추부이행부는 40%, 요추부는 50% 이상의척추관이골편에의해점유되어있는경우이차적인전방감압술이필요하다고보고되었다. 9) 본연구에서는신경학적증상을동반한흉요추골절환자에대한후방감압술및유합술을시행하고수술후 CT촬영에서척추관함입률이 40% 이상이면서신경학적증상의호전이없는환자들은추가적으로전방감압술및유합술을하여서두군간의신경학적호전정도를평가하여전방감압술이신경회복에도움이되는가를알아보자하였다. 연구결과에서는후방감압술군에서 69%, 전후방감압술군 67% 가 Frankel grade 1단계이상의신경학적호전을보였으나, 두군간에의의있는차이는없었으며신경호전의정도는다른대부분의저자들과비슷한결과를보였다. 6,10-13) Fontijne 등 14) 은흉요추골절에서골절편의척추관함입의정도와신경학적결손과는의미있는상관관계가있다고보고하였으나, Mohanty 와 Venkatram 15) 은흉요추및요추방출성골절에서척추관함입의정도와신경학적결손및회복과는상관관계가없다고보고하였다. 척수나신경근은척추골절후후방으로전이되는척추체골편에의해손상될수있지만신경손상의정도는방사선및 CT에서확인되는척추관내로전위된골편의크기나척추관의협착보다는신경학적검사가더정확하며, 손상의정도를효과적으로나타낼수있을것이다. 저자들이시행한수술방법은, 후방감압을위한추궁판절제술로손상받지않은 35

7 Jae-Won You et al Volume 19 Number 2 June 2012 후방구조물을가능한보존하면서신경증상이심한부분은추궁판절제술을하고반대편은 1/3정도의추궁판을남겨두어후외방유합술의골이식범위를확보하였고흉요추부인경우에는장분절고정을, 요추부인경우에는가동운동분절을최대한남기기위해척추경손상이없는경우에는골절된추체에도일측성나사못을삽입하는단분절고정을하였다. 합병증으로발생한내고정물의파손은후방감압술군에서더많았는데이는생역학적측면에서볼때후방유합술이전방유합술보다는더약하다는기존의개념을확인해주는결과인것으로판단된다 ) 굴곡-신연손상은요추보다는흉요추부에서더많이발생하며본연구에서도전예에서흉요추부에서발생하였다. 수상부위의극간인대손상이나극돌기의횡골절이있는경우에굴곡- 신연손상으로분류되었으며수술방법이나후방유합범위는방출성골절과특별한차이를두지않았다. 굴곡-신연손상환자에서전방감압술을추가한경우는 1예 (7%) 이었으며, 방출성골절에서전방감압술을추가한경우는 12예 (55%) 로골절편의척추관함입은대부분방출성골절환자에서신경손상을유발하는것으로판단된다. 연구대상에서대부분의환자 (82%) 가 Frankel grade D로신경학적증상은자연히호전될가능성이있는환자들이며, 후방수술후 1-2주간신경학적변화를평가한후전방수술을추가해서충분한기간동안신경학적변화를관찰하지못하고전방수술을추가한것은본논문의제한점이라고볼수있다. 본논문의결과에서는후방감압술만시행한군과전후방감압술을시행한군에서신경학적호전의정도에차이를보이지않았는데이는신경학적호전이수술의방법보다는수상당시의외력의크기나조기감압여부등다른요인이더영향을미치는것으로생각된다. 다만골절의안정성은전방유합술이더우수하므로안정성을추가하기위한전방유합술은충분히고려할수있다고판단된다. 결론 신경학적증상을동반한흉요추및요추골절의치료에서후방감압술과전후방감압술의신경증상호전의정도는차이가없으므로후방감압술후신경호전을위한추가적인전방감압술은꼭필요한술식은아니라고사료됩니다. REFERENCES 1. Zdeblick TA, Sasso RC, Vaccaro AR, Chapman JR, Harris MB. Surgical treatment of thoracolumbar fractures. Instr Course Lect. 2009;58: Ozturk C, Ersozlu S, Aydinli U. Importance of greenstick lamina fractures in low lumbar burst fractures. Int Orthop. 2006;30: Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop Relat Res. 1987;218: McAfee PC, Yuan HA, Lasda NA. The unstable burst fracture. Spine (Phila Pa 1976). 1982;7: Frankel HL, Hancock DO, Hyslop G, et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia. 1969;7: Rath SA, Kahamba JF, Kretschmer T, Neff U, Richter HP, Antoniadis G. Neurological recovery and its influencing factors in thoracic and lumbar spine fractures after surgical decompression and stabilization. Neurosurg Rev. 2005;28: Magerl F, Aebi M, Gertzbein SD, Harms J, Nazarian S. A comprehensive classification of thoracic and lumbar injuries. Eur Spine J. 1994;3: Oner FC, Wood KB, Smith JS, Shaffrey CI. Therapeutic decision making in thoracolumbar spine trauma. Spine (Phila Pa 1976). 2010;35(21 Suppl):S Denis F, Burkus JK. Diagnosis and treatment of cauda equina entrapment in the vertical lamina fracture of lumbar burst fractures. Spine (Phila Pa 1976). 1991;16(8 Suppl):S Denis F, Burkus JK. Shear fracture-dislocations of the thoracic and lumbar spine associated with forceful hyperextension (lumberjack paraplegia). Spine (Phila Pa 1976). 1992;17: Aebi M, Etter C, Kehl T, Thalgott J. Stabilization of the lower thoracic and lumbar spine with the internal spinal skeletal fixation system. Indications, techniques, and first results of treatment. Spine (Phila Pa 1976). 1987;12: Tasdemiroglu E, Tibbs PA. Long-term follow-up results of thoracolumbar fractures after posterior instrumentation. Spine (Phila Pa 1976). 1995;20: Wiberg J, Hauge HN. Neurological outcome after surgery for thoracic and lumbar spine injuries. Acta Neurochir (Wien). 1988;91: Fontijne WP, de Klerk LW, Braakman R, et al. CT scan prediction of neurological deficit in thoracolumbar burst 36

8 Journal of Korean Society of Spine Surgery Additional Anterior Decompression for Thoracolumbar and Lumbar Fractures fractures. J Bone Joint Surg Br. 1992;74: Mohanty SP, Venkatram N. Does neurological recovery in thoracolumbar and lumbar burst fractures depend on the extent of canal compromise? Spinal Cord. 2002;40: Gurr KR, McAfee PC, Shih CM. Biomechanical analysis of anterior and posterior instrumentation systems after corpectomy. A calf-spine model. J Bone Joint Surg Am. 1988;70: McCormack T, Karaikovic E, Gaines RW. The load sharing classification of spine fractures. Spine (Phila Pa 1976). 1994;19: Lim TH, An HS, Hong JH, et al. Biomechanical evaluation of anterior and posterior fixations in an unstable calf spine model. Spine (Phila Pa 1976). 1997;22: 신경학적증상을동반한흉요추및요추골절에서후방감압술후추가적인전방감압술이필요한가? 유재원 손홍문 박상수조선대학교의과대학정형외과학교실, 척추센터 연구계획 : 후향적연구 목적 : 신경학적증상을동반한흉요추및요추골절환자에서후방감압술로치료한후신경증상의호전을위해서전방감압술이추가적으로필요한지 에대해서알아보고자하였다. 선행문헌의요약 : 후방감압술후척추관내골편이남아있는경우전방감압술이필요한지에대한일치된의견은확립되지않았다. 대상및방법 : 신경학적증상을동반한흉요추부및요추골절로인해수술적치료를받은환자중 1 년이상추시관찰이가능하였던 38 예를대상으로 하였다. 후방감압술과유합술만받은예는 26 예, 전후방감압술을받은예는 12 예이었다. 신경학적증상은 Frankel grade A 가 3 예, B 가 1 예, C 가 3 예, D 가 31 예이었다. 골절의분류는 McAfee 등의분류에따라불안정성방출성골절 22 예, 굴곡신연손상 12 예, Chance 골절 2 예, 전이성손상 2 예이었 다. 방사선학적평가는양군의척추관함입률과후만각을비교하였으며, 수술전척추관함입률과신경학적호전의정도를비교하였다. 결과 : 수술소견상신경근손상은후방감압술군 5 예에서, 전후방감압술군 4 예에서확인되었다. 후방감압술군에서호전 18 예 (69%), 무변화 8 예 (31%) 이었으며전후방감압술군에서호전 8 예 (67%), 무변화 4 예 (33%) 를보여두군간에의의있는신경학적호전의차이는없었다 (p>0.05). 수술전척추관 함입률은후방감압술군 62%, 전후방감압술군 67% 로전후방감압술군에서척추관함입이많았으나, 수술전척추관함입률과최종신경학적증상의 호전과는두군간에의의있는차이는없었다 (p>0.05). 결론 : 신경학적증상을동반한흉요추및요추골절의치료에서후방감압술과전후방감압술의신경호전의정도는차이가없었으며신경호전을위한 추가적인전방감압술은꼭필요한술식은아니라고사료됩니다. 색인단어 : 흉요추골절, 신경학적증상, 후방감압술, 전방감압술 약칭제목 : 흉요추골절에서추가적인전방감압술 37

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar