01-김환정

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1 대한척추외과학회지제 15 권제 4 호 Journal of Korean Spine Surg. Vol. 15, No. 4, pp 215~222, 2008 경추전방유합술후인접분절의퇴행성변화 김환정 강종원 성환일 박건영 # 박재국 $ 강성일 최원식 을지대학교의과대학정형외과학교실, 대전보훈병원정형외과 #, 홍성의료원정형외과 $ Degenerative Changes of Adjacent Segment after Anterior Cervical Discectomy and Fusion Abstract Whoan Jeang Kim, M.D., Jong Won Kang, M.D., Hwan Il Sung, M.D., Kun Young Park, M.D. #, Jae Guk Park, M.D. $, Sung Il Kang, M.D., Won Sik Choy, M.D. Department of Orthopaedic Surgery, Eulji University School of Medicine, Daejeon, Department of Orthopaedic Surgery, Daejeon Veterans Hospital #, Daejeon, Department of Orthopaedic Surgery, Hongseong Medical Center, Hongseong $, Korea Study Design: A retrospective radiologic analysis of 34 patients Objectives: To evaluate the factors influencing the radiographic degenerative changes in the adjacent segments in one-level ACDF (ed note: define ACDF). Summary of Literature Review: There is a 25% incidence of adjacent segment degeneration after 5 years. Materials and Method: From 2002 to 2005, 34 patients (male 23, female 11) underwent anterior cervical spine fusion using a cage or bone block for degenerative cervical spine. The mean age of the patients was 51 years and the mean follow-up period was 24 months. The degenerative findings of the upper and lower adjacent segment were measured from the pre-operative MRI. The fused segment curvature, disc heights of the adjacent segments, displacement of the vertebral bodies and angular mobility in the adjacent segments were measured from the pre-operative and final follow-up lateral views in the neutral position, in both flexion and extension. Results: Degenerative changes in the adjacent segments were observed in 19 of the 34 patients. The group with degenerative changes showed significantly more lordotic angular loss of the fusion segments (11.9±3.1 ) at the follow-up observation than the group with no degenerative changes (9.0±1.1 ) (p=0.04). The group with degenerative change showed a significantly larger increase in disc height of the fusion segments (2.8±0.2 mm) at the follow-up observation than the group with no degenerative changes (2.2±0.3 mm) (p=0.02).the group with a Grade IV or higher level of pre-operative disc degeneration showed more degenerative changes in the adjacent segments than those with Grade III or lower. Conclusions: It is important to preserve the lordotic angle of fused segments and avoid excessive increases in disc height. The recurrence of the neurological is not associated with the preoperative adjacent segmental degenerative changes in ACDF. Key Words: Anterior cervical discectomy and fusion, Adjacent segments, Degenerative change Address reprint requests to Jong Won Kang, M.D. Department of Orthopaedic Surgery, Eulji University College of Medicine, 1306, Dunsan-dong, Seo-gu Daejon, , Korea Tel: , Fax: , jwkang@eulji.ac.kr

2 대한척추외과학회지 Vol. 15, No. 4, 2008 서 론 경추신경근증이나척수증에대하여전방감압및유합술을시행할경우인접분절의방사선학적변화와함께새로운신경근증이나인접분절문제가매년약 3% 정도로, 10 년이내에 25% 이상에서발생한다고보고되고있다. 인접분절의변화가전방유합술에서뿐만아니라 posterior foraminotomy 를시행한후에도같은정도로보고되고있고, 또한다분절유합에서보다단분절에서더많이발생한다고알려져있기때문에 adjacent segment disease 가전방유합술의결과인지아니면경추증 (cervical spondylosis) 의자연경과인지에대해서는논란의여지가많다. 저자들은단분절추간판탈출증으로전방감압및유합술을시행한환자를대상으로수술전과최종추시에서유합분절의추간판높이의변화, 유합분절의만곡, 유합인접분절의추간판높이, 유합인접분절의추체전위및각운동의변화를측정하여퇴행성병변과의관계및영향을미치는인자에대해알아보고자한다. 대상및방법 1. 연구대상 2002 년 2 월부터 2005 년 7 월까지단분절경추추간판탈출증으로진단받고전방감압과 cage 또는 bone block 을이용한유합술을시행한 50 례중 1 년이상추시가가능한 34 례를대상으로하였다. 환자의평균연령은 51 세이었고, 퇴행성변화를보인군 50 세, 퇴행성변화를보 이지않은군 52 세이었다. 성별은남자 23 명, 여자 11 명이었고, 퇴행성변화를보인군의남자는 13 명, 여자 6 명, 퇴행성변화를보이지않은군의남자는 10 명, 여자 5 명이었다. 평균추시기간은 24 개월 (18~48 개월 ) 이었다 (Table 1). 2. 연구방법 술전과최종추시시의측면방사선사진을굴곡및신전, 중립위에서촬영하여유합분절의만곡, 유합분절과유합인접분절의추간판높이, 유합인접분절의추체전위및각운동의변화를측정하였다. 유합분절의전만각은유합분절상하연의연장선이만나는각으로하였다 (Fig. 1). 경추의운동범위는굴곡및신연사진에서각각의경추운동각의합으로하였으며, 각운동의변화는최종추시굴곡및신연사진에서상부추체의하연과하부추체의상연이이루는각의합으로하였다 (Fig. 2). 추간판높이의측정은추간판의전방높이와후방높이합의평균값으로하였다. 수술전측면단순방사선사진과비교하여아래 3 가지중한가지라도나타나면유합인접분절의퇴행성변화가생긴것으로평가하였다 mm 이상의추간판높이의감소 2. 추체의전방또는후방골극형성 3. 굴곡및신전사진상시상면에서 3 mm 이상전위또는인접분절의각운동이 Dvorak 등 1) 의정상각운동이상의운동을보인경우 (Table 2). 술전 MRI 를통해상, 하인접추간판의퇴행성정도를 Modified Pearce classification 을이용측정하여 5 가지군으로분류하였다. Table 1. Baseline characteristics of the study population Total Degenerative change (+) Degenerative change (-) Mean age Gender (M:F) 23:11 13:6 10:5 Mean follow up Table 2. Summary of the normal values estabilished by different authors ( ) Bakke Buetti-Bauml De Seze Penning Dvorak C1-C C2-C C3-C C4-C C5-C C6-C

3 경추전방유합술후인접분절의퇴행성변화 김환정외 Fig. 1. Measurement of the alignment of the fused segment (angle A). Angle A was formed by the upper plane and lower plane of the fused segment. grade I: 이상소견이없는경우 grade II: MRI 소견상 T2 강조영상에서저신호강도만보이는경우 grade III: MRI 소견상시상면, 축상면상에서추간판의팽윤또는돌출소견이보이는경우 grade IV: MRI 소견상축상면상에서섬유륜의파열이있는경우 grade V: 단순방사선사진에서는잘보이지않는후방골극이관찰된경우통계학적분석은 t-test 와 Chi-Square test 를이용하였다. 3. 수술방법 전례에서 Smith 와 Robinson 의전방도달법을이용하였고, 병변추체주위의골극과환부의추간판및상하추체의말단연골판을제거한뒤후종인대전방의추간판과골극까지완전히제거하였다. 이후인접추체사이의길이를측정한뒤장골능에서피질해면골골편을채취하여추체사이에삽입하거나, 장골능에서채취한해면골을채워넣은 cage 를추체사이에삽입하였다. 수술후에는 Philadelphia brace 를 6 주간착용하였다. 결 과 저자들의기준에따라퇴행성변화를보인군과정상인군으로구분하였다. 수술분절로는경추 3-4 번이 2 례, 경추 4-5 번이 5 례, 경추 5-6 번이 20 례, 경추 6-7 번이 7 례였다. 34 례중 19 례 (55.9%) 에서유합인접분절에서단순방사선소견에의한퇴행성변화를보였으나, 신경증상의악화로인한재수술은없었다. 인접분절의추간판높이가 1 mm 이상감소한경우는총 11 례 (32.3%) 로윗분 Fig. 2. Changes in the motion segment between vertebrae. Calculation of the angular displacement of the flexion/ extension views. 절 4 례와아랫분절 7 례였다. 굴곡및신전사진상시상면에서 3 mm 이상전위가있는경우는 9 례 (26.5%) 였다. 인접분절의각운동이정상적인경추운동범위이상의운동을보인경우는 9 례 (26.5%) 였다. 1. 유합분절의전만각과인접분절의퇴행성변화 술후유합분절의전만각은인접분절에퇴행성변화를보인군에서는 12.1±4.9, 퇴행성변화를보이지않은군에서는 13.8±2.9 로통계학적으로유의한차이를보이지않았다 (p>0.05). 최종추시시유합분절의전만각은인접분절에퇴행성변화를보인군에서는 1.1±0.2, 퇴행성변화를보이지않은군에서는 4.8±4.0 로통계학적으로유의한차이를보이지않았다 (p>0.05). 최종추시시술후와비교한유합분절의전만각감소량은인접분절에퇴행성변화를보인군에서는 11.9±3.1, 퇴행성변화를보이지않은군에서는 9.0±1.1 로통계학적으로유의한차이를보였다 (p=0.04, Fig. 3). 2. 유합분절의추간판높이와인접분절의퇴행성변화 술전유합분절의추간판높이는인접분절에퇴행성변화를보인군에서는 4.8±0.5 mm, 퇴행성변화를보이지않은군에서는 4.4±0.3 mm 로통계학적으로유의한차이를보이지않았다 (p>0.05). 술후유합분절의추간판높이는인접분절에퇴행성변화를보인군에서는 7.5± 0.8 mm, 퇴행성변화를보이지않은군에서는 7.1±0.5 mm 로통계학적으로유의한차이를보이지않았다 (p>0.05). 수술전후유합분절추간판높이의변화량은인접분절에퇴행성변화를보인군에서는 2.8±0.2 mm, 퇴행성변화를보이지않은군에서는 2.2±0.3 로통계학적으로유의한차이를보였다 (p=0.02)

4 대한척추외과학회지 Vol. 15, No. 4, 2008 Fig. 3. A 42-year-old woman, disc herniation at C3-4 and treated with anterior cervical disectomy and fusion. (A) Preoperative lateral radiograph, (B) Radiograph at postoperative 2-years follow-up shows solid union and maintained lordosis at fusion segment (10 ), (C, D) At last follow-up, adjacent intervertebral segment shows degenerative change, angular motion is within normal limit but sagittal translation is 3 mm. Table 3. Inflencing factors in degenerative change of adjacent segment 퇴행성병변 (+) 퇴행성병변 (-) p-value 유합분절술후전만각 12.1± ± 유합분절추시후전만각 1.1± ± 유합분절전만각변화량 12.3± ± 유합분절술전추간판높이 4.8± ± 유합분절술후추간판높이 7.5± ± 유합분절추간판높이증가량 2.8± ± 술전윗분절추간판간격 5.7± ± 술전아랫분절추간판간격 5.6± ± 유합인접분절의추간판높이와퇴행성변화 술전윗분절추간판간격은퇴행성변화를보인군에서는 5.7±0.6 mm, 퇴행성변화를보이지않은군에서는 4.8±1.1 mm 로통계학적으로유의한차이를보이지않 았다 (p>0.05). 술전아랫분절추간판간격은퇴행성변화를보인군에서는 5.6±0.8 mm, 퇴행성변화를보이지않은군에서는 6.5±1.1 mm 로통계학적으로유의한차이를보이지않았다 (p>0.05, Table 3)

5 경추전방유합술후인접분절의퇴행성변화 김환정외 Table 4. Preoperative degenerative findings and radiologic result 4. 유합인접분절의술전 MRI 상퇴행성변화정도와술후퇴행성변화 윗분절에서술전 MRI 상 grade III 이하인군에서최종추시시 50%, grade IV 이상인군에서 70% 의퇴행성변화를보였고, 아랫분절에서술전 MRI 상 grade III 이하인군에서최종추시시 50%, grade IV 이상인군에서 83% 의퇴행성변화를보였으나통계학적으로유의한차이를보이지않았다 (p>0.05, Table 4). 고 찰 Grade I~III Grade IV~V 윗분절 아랫분절 28 6 윗분절퇴행성변화 (-) 12 3 윗분절퇴행성변화 (+) 12 7 아랫분절퇴행성변화 (-) 14 1 아랫분절퇴행성변화 (+) 14 5 경추전방감압및유합술은비교적도달이쉽고출혈이적으며수술시야가좋고수술후경추운동범위제한이적은수술로 2,3) Bailey 와 Badgeley 4), Smith 와 Robinson 5), Cloward 6) 등에의해시작되어경추의병변, 즉퇴행성병변에의한척수병증이나신경근증의치료에널리이용되고있으며좋은결과를보고하고있다 7,8,9). 경추전방감압및유합술에서수술후합병증은비교적드문것으로알려져있으며, 속발형과지연형으로크게 2 가지로나누어볼수있다. 속발형합병증에는척추동맥의손상이나경부의혈종, 후방후두부부종, 식도나기도의손상, 회귀인두신경의손상, 호너증후군등이있으며, 지연형합병증에는감염, 유합부위의불안정운동, 척추관협착증, 추간판병변그리고인접분절의퇴행성변화등이보고되고있다. 특히경추전방감압및유합술후장기추시에서유합인접분절의퇴행성변화는비교적높은빈도로나타나며 10,8), 이에대한유발인자, 예방법혹은진단기준등은아직확실치않으며, 저자마다의견이분분하다. 또한전방유합술의결과인지아니면경추증 (cervical spondylosis) 의자연경과인지에대해서도논란의여지가많다. Hiroto 등 11) 은사람과동물을대상으로한실험에서유합부위에인접한운동가능분절에서운동범위의증가를발견하였고, 유합된추체의수가증가할수록인접운동가능분절의운동범위가증가하였다고발표하였다. 실제로 Cineroentgenography 를 이용해촬영하면경추분절유합상하모든분절에서운동이증가하고인접분절에서최대로증가하는것을알수있다. 이렇게증가된분절운동이인접분절의퇴행성병변을촉진시킨다고보고하였다 12,13). Jiayong 등 19) 은유합방법에상관없이경추유합시인접분절에운동성이부가되어퇴행성변화를촉진시킨다고하였고, 7.2 년의추시결과 31% 에서통증의재발을일으켰으며, 17.8% 에서재수술을하였다고발표하였고, Hilibrand 등 15) 은경추전방감압및유합술후 2.9% 에서인접분절의퇴행성변화를발표하였다. 요추유합후의부정정렬이유합인접분절의퇴행성병변을촉진시킨다고하는보고들은있었으나 16,17), 경추유합후의부정정렬이경추인접분절에해로운영향을미친다는보고는드물다 18). 경추유합후의전만각의감소가정상적인전만이유지되었을때와는달리인접분절응력분포에변화를일으키게되며, 후만은경추의굴신운동시인접분절에후방활주력을증가시키고후주에가해지는장력이증가하게되어 17), 유합분절이나인접분절의퇴행성변화가초래되게된다고알려져있다. 저자들의경우최종추시시술후와비교하여유합분절전만각의감소량은퇴행성변화를보인군에서퇴행성변화를보이지않은군에비해더크게나타났다. 다시말하면유합분절의전만각의감소가인접분절의퇴행성변화를더초래하였고, 그원인으로는이식골의흡수나 cage 의인접추체로의침강때문이었다. An 등 19) 은기본추간판높이보다 2 mm 정도큰것이가장적절한추간판의높이, 신경공의높이및후관절면의접촉을얻을수있다고하였으며, Jiayong 등 19) 은 C4-5 에서추간판높이가 1 mm 증가함에따라신경공이 0.8 mm 증가하는반면에후관절면의접촉부위가 8% 씩감소한다고하였다. 결론적으로는추간판높이의적절하지못한증가가후관절면의접촉부위를감소시켜아탈구를유발할수있다고하였다. 그러나어느정도까지추간판높이를늘리는지에대해서는알려진바가없다. 본연구에서는퇴행성변화를보인군에서유합분절추간판높이의증가량이더크게나타났으나, 가장적절한추간판높이에대해서는추시기간이짧고, 증례의수가적어추가적인연구가필요하리라사료된다. 유합인접분절이수술전에이미퇴행성변화가있는상태에서는유합술시행이인접분절의퇴행성변화를더욱빠르게진행시킨다는것이널리알려져있다 20,21,22,23). 퇴행성변화를알수있는방사선사진소견은추간판의높이가감소하게되고, 퇴행성변화가진행함에따라주위골조직에도변화가병행하여추체종판의경화상, 골극의형성, 후관절의비후등이나타난다. 또한후관절의손상으로분절불안정소견을보일수도있다 24,25). 본연

6 대한척추외과학회지 Vol. 15, No. 4, 2008 구에서도 MRI 상술전추간판퇴행성정도가 grade Ⅳ 이상인군에서 grade III 이하인군에비해인접분절의퇴행성변화가더많이나타났다. 단순방사선소견상의변화, CT 나 MRI 에의해제공되어지는술전퇴행성변화가수술후의퇴행성변화와연관성이있으므로수술시세심한주의가필요할것으로사료된다. 결 론 단분절경추추간판탈출증에서전방감압및유합술을시행할경우, 최종추시시술후와비교한유합분절의전만각감소량과수술전후유합분절추간판높이의변화량이유합인접분절의퇴행성변화와관련이있다. 따라서인접분절의퇴행성변화를감소시키기위해술후유합분절의전만각을유지하도록주의를기울여야하며수술시추간판높이의과도한증가를피하는것이좋을것으로사료된다. 참고문헌 01) Dvorak J, Froehlich D, Penning L, Baumgartner H, Panjabi MM: Funtional radiographic dianosis of the cervical spine:flection/extention. Spine 1988; 13: ) Connolly PJ, Esses SI, Kostuik JP: Anterior cervical fusion: outcome analysis of patients fused with and without anterior cervical plates. J Spinal Disord 1996; 9: ) Suh Pb, Kostuik JP, Esses SI: Anterior cervical plate fixation with the titanium hollow screw plate system. A preliminary report. Spine 1990; 10: ) Bailey RW, Badgley CE: Stabilization of the cervical spine by anterior fusion. J bone Joint Surg 1960; 42-A: ) Robison RA, Smith GW: Anterolateral cervical disk removing and interbody fusion for cervical disk syndrome. Bull John Hopkins Hospital 1955; 96: ) Cloward RB: Treatment of acute fractures and fracturedislocations of the cervical spine by vertebral body fusion.a report of eleven cases. J Neurosurg 1958; 18: ) Bohlman HH, Emery SE, Goodfellow DB, Jones PK: Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy : Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am 1993; 75: ) Gore DR, Sepic SB: Anterior cervical fusion for degenerated or protruded discs: A review of one hundred forty-six patients. Spine 1984; 9: ) Goto S, Mochizuki M, Kita T et al: Anterior surgery in four consecuitive tachnical phases for cervical spondylotic myelopathy. Spine 1993; 18: ) Braunstein EM, Hunter LY, Bailey RW: Long term radiographic changes following anterior cervical fusion. Clin Radiol 1980; 31: ) Hiroto N, Michael JS, Ensor ET, Jack LL: The effect of immobilization of long segments of the spine on the adjacent and distal facet force and lumbosacral motion. Spine 1993; 18(16): ) Dohler JR, Kahn MR, Hughes SP: Instability of the cervical spine after anterior interbody fusion. A study on its incidence and clinical significance in 21patients. Acta Orthop truma Surg 1985; 104: ) Fuller DA, Kirkpatrick JS, Emery SE, Wilber RG, Davy DT: A kinematic study after cervical spine before and after segmental arthrodesis. Spine 1998; 23: ) Jiayong Liu, Nabil Ebraheim, Steven Haman et al: How the increase of the cervical disc space height affects the facet joint. Spine 2006; 31: ) Hilibrand AS, Carlson GD, Palumbo MA et al: Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J bone joint Surg Am 1999; 81: ) Jackson RP, McMaus AC: Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age,sex and size: a prospective controled clinical study. Spine 1994; 19: ) Oda I, Cunningham BW, Buckley RA et al: Does spinal kyphotic deformity influence the biomechanical characteristics of the adjacent motion segments An in vivo animal model. Spine 1999; 24: ) Katsuura A, Hukuda S, Saruhashi Y, Mori K: Kyphotic malaligment after anterior cervical fusion in one of the factors promoting the degenerative process in adjacent intervetebral levels. Eur Spine 2001; 10: ) An HS, Evanich C, Nowicki B, Haughton V: Ideal thickness of Smith-Robinson graft for anterior cervical fusion. Spine 1993; 18: ) Gore DR, Sepic SB: Anterior discectomy and fusion for painful cervical disc disease.a report of 50 patients with

7 경추전방유합술후인접분절의퇴행성변화 김환정외 an average follow-up of 21 years. Spine 1998; 23: ) Shinomiya K, Okamoto A, Kamikozuru M, Furuya K, Yamaur I: An analysis of failures in primary cervical anterior spinal cord decompression and fusion. J Spinal Disord 1993; 6: ) Wu W, Thuomas KA, Hedlund R, Leszniewski W, Vavruch L: Degenerative changes following anterior cervical discectomy and fusion evaluated by fast spin-echo MR imaging. Acta Radiol 1996; 37: ) Yonenobu K, Okada K, Fuji T, Fujiwara K, Yamashita K, Ono K: Cause df neurologic deterioration following surgical myelopathy. Spine 1986; 11: ) Gore DR, Gardner GM, Sepic SB, Murray MP: Roentgenographic findings following anterior cervical fusion. Skeletal Radiol 1986; 15: ) Hunter LY, Braunstein EM, Bailey RW: Radiographic changes following anterior cervical fusion.spine 1980; 5:

8 대한척추외과학회지 Vol. 15, No. 4, 2008 국문초록 연구계획 : 경추신경근증이나척수증에대하여전방감압및유합술을시행할경우인접분절의방사선학적변화와함께새로운신경근증이나인접분절문제가매년약 3% 정도로, 10년이내에 25% 이상에서발생한다고보고되고있다. 또한전방유합술에서뿐만아니라 posterior foraminotomy를시행한후에도같은정도로보고되고있고, 다분절유합에서보다단분절에서더많이발생한다고알려져있기때문에 adjacent segment disease가전방유합술의결과인지아니면경추증 (cervical spondylosis) 의자연경과인지에대해서는논란의여지가많다. 연구목적 : 단분절전방감압및유합술을시행한후방사선학적으로인접분절의변화와이에영향을미치는인자들에대하여알아보고자하였다. 대상및방법 : 2002년 2월부터 2005년 7월까지단분절경추추간판탈출증으로진단받고전방감압과 cage또는 bone block을이용한유합술을시행한 50례중 1년이상추시가가능한 34례 ( 남자 23명, 여자 11명 ) 를대상으로하였다. 환자의연령은평균 51세이었고, 평균추시기간은 24개월 (18~48개월) 이었다. 술전 MRI 에서상, 하인접추간판의퇴행성정도를 Modified Pearce classification을이용하여측정하였고, 술전과최종추시시의측면방사선사진을굴곡및신전, 중립위에서촬영하여유합분절의만곡, 유합분절과유합인접분절의추간판높이, 유합인접분절의추체전위및각운동의변화를측정하였다. 결과 : 34례중19례에서인접분절의퇴행성변화를보였으나신경증상의악화로인한재수술은없었다. 최종추시시술후와비교한유합분절의전만각감소량은인접분절에퇴행성변화를보인군에서는 11.9±3.1, 퇴행성변화를보이지않은군에서는 9.0±1.1 로통계학적으로유의한차이를보였다 (p=0.04). 수술전후유합분절추간판높이의변화량은인접분절에퇴행성변화를보인군에서는 2.8±0.2 mm, 퇴행성변화를보이지않은군에서는 2.2±0.3 mm로통계학적으로유의한차이를보였다 (p=0.02). 윗분절에서술전 MRI상 grade Ⅲ 이하인군에서최종추시시 50%, grade Ⅳ 이상인군에서 70% 의퇴행성변화를보였고, 아랫분절에서술전 MRI상 grade Ⅲ 이하인군에서최종추시시 50%, grade Ⅳ 이상인군에서 83% 의퇴행성변화를보였으나통계학적으로유의한차이를보이지않았다 (p>0.05). 결론 : 단분절경추추간판탈출증에서전방감압및유합술을시행할경우, 최종추시시술후와비교한유합분절의전만각감소량과수술전후유합분절추간판높이의변화량이유합인접분절의퇴행성변화와관련이있다. 따라서인접분절의퇴행성변화를감소시키기위해술후유합분절의전만각을유지하도록주의를기울여야하며수술시추간판높이의과도한증가를피하는것이좋을것으로사료된다. 색인단어 : 경추전방유합술, 인접분절, 퇴행성변화 통신저자 : 강종원대전광역시서구둔산동 1306 을지대학교의과대학정형외과학교실 Tel: Fax: jwkang@eulji.ac.kr

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